1. Anterior temporal lobectomy for epilepsy: success and shortcomings Dario J. Englot, visiting student Yale MD/PhD Program September 24, 2009 Department of Neurosurgery

2.  61-year-old right-handed male with seizures for past 20 years  per pt: daily “day dreaming” spells, losing touch with reality  per wife: during seizures, face droops, clears throat, says “okay” repeatedly, non responsive for ~30s  no aura; somewhat confused for several minutes afterwards  has failed management with multiple anti-epileptics: depakote, carbamazepine, lamotrigine, levetiracetam  PMH/PSH: retinal and shoulder surgeries  Meds: levetiracetam, ASA, MVI NKDA  SH: married engineer, no substance abuse FH : no epilepsy Patient history

3.  All vital signs in normal limits, and normal cardiopulmonary exam  Neurological exam: no deficits detected in mental status, cranial nerves, strength, sensation, reflexes, cerebellar function, or gait  Scalp EEG monitoring shows clinical episodes are associated with left temporal seizure activity  MRI, PET (outside hospital) Physical exam and tests

4. MRI

6. PET

7.  Left anterior temporal lobectomy  Dr. Emad Eskandar  Assist: Dr. Jason Gerrard  Post-operatively  expressive aphasia for a few hours  urinary retention: treated  full, uneventful recovery afterwards Operative course

8. Post-Op MRI

9. Blumenfeld (2002) Neuroanatomy Hippocampal sclerosis: in 50-70% of resected hippocampi DeLanerolle (2003) Epilepsia Eid et al (2007) Acta Neuropathol Hippocampus in mesial temporal lobe epilepsy (MTLE)

10.  Medically refractory seizures with diminished QOL?  History, neurology consultations, and neuropsychology reports  Localizable lesion or seizure focus?  Scalp or intracranial electrode EEG (ictal, interictal)  MRI (interictal)  PET (interictal)  SPECT (ictal, interictal)  Localized seizure focus in a resectable region?  fMRI  Wada  Language mapping  Neuropsychological evaluation MTLE: Who should have surgery? Spencer (2002) The Lancet Berg et al (2003) Epilepsia

11. Spencer and Huh (2008) The Lancet Temporal Lobectomy Outcomes

12.  Identifiable lesions and consistent imaging and electrophysiological findings improve outcomes  Some “good” surgical candidates, including those with unilateral temporal lobe sclerosis, nevertheless have recurrence post-operatively  Pathogenesis: Incomplete resection of epileptogenic lesions vs. new epileptogenicity Why does surgery sometimes fail?

13.  Extent of resection: anterior lobectomy vs. selective amygdalohippocampectomy  Cohort study,100 patients (50 each surgery), followed 5 yr: no statistical difference in recurrence rates 1  Demographics: age, sex, or duration of epilepsy  Retrospective chart review, 105 patients, followed up to 3 yr: no relationship between factors & recurrence 2 1) Tanriverdi et al (2008) J Neurosurg 2) Ramos et al (2009) J Neurosurg Why does surgery sometimes fail?

14.  Pre-op electrophysiology and imaging results  Retrospective review, 118 pts, followed 1 yr: similar data with/without recurrence 1 (also found in previously mentioned study 2 )  Historical risk factors: head trauma, tuberous sclerosis, VP shunts, AVMs, CNS infection, global hypoxia, febrile seizures, status epilepticus  118 patients followed 1 yr: only status epilepticus showed prediction (p = 0.0276) of a higher recurrence rate 1 Why does surgery sometimes fail? 1) Hardey et al (2003) Epilepsia 2) Ramos et al (2009) J Neurosurg

15.  Discontinuation of antiepileptic drugs (AEDs)  6 retrospective clinical studies each with > 5 patients taken off meds (total N = 54-210 per study)  Sironi et al (1983) Riv Neurol; Murro et al (1991) J Epilepsy; Schiller et al (2000) Neurology; Van Veelan (2001) Ned Tijdschr Geneeskd; Al-Kaylani (2002) Epilepsia; Lachhwani (2003) Neurology  Relapse rate after AEDs D/Ced: 32-36% (f/u 1-6 yr)  Relapse rate with AEDs onboard: 7-17% (f/u 1-5 yr)  No benefit of waiting to attempt AED D/C after 2 yr in adults and 1 yr children Reviewed in: Hardey et al (2003) Epilepsia Why does surgery sometimes fail?

16. Schmidt (2004) Epilepsia Seizure-free (%)

17.  Limitation: possible selection bias with retrospective observations  Further study: need randomized, double-blind, placebo-controlled trial of AED continuation vs. discontinuation 2 yr post-op AED discontinuation after temporal lobectomy Hardey et al (2003) Epilepsia (review); Sironi et al (1983) Riv Neurol; Murro et al (1991) J Epilepsy; Schiller et al (2000) Neurology; Van Veelan (2001) Ned Tijdschr Geneeskd; Al-Kaylani (2002) Epilepsia; Lachhwani (2003) Neurology

18.  Medically-refractory mesial TLE can often be treated successfully with temporal lobe resection  Seizure recurrence post-operatively can be difficult to predict, but may be reduced with sustained (> 2 yr) anti-epileptic therapy  To the faculty, residents, and staff of MGH neurosurgery Conclusions Thank you