RS for unilateral mesial temporal lobe epilepsy offers seizure remission rates comparable with those reported previously for open surgery. There were no major safety concerns with high-dose RS compared with low-dose RS. Additional research is required to determine whether RS may be a treatment option for some patients with mesial temporal lobe epilepsy.

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.

Background: Stereotactic radiosurgery (RS) is a promising treatment for intractable medial tem-

OBJECTIVE Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control. METHODS The authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up. RESULTS Of 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p < 0.001). The mean follow-up was 59 ± 35 months for MVD and 59 ± 45 months for SRS. Approximately 38% of patients who underwent MVD or SRS had > 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th-75th quartiles: 57-131 months) for MVD and 53 months (25th-75th quartiles: 37-69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001-1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213-0.723; p = 0.003) were associated with favorable outcome for SRS. CONCLUSIONS In this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon...

Surgical treatment is increasingly used for patients with medically re fractory seizures. Valproate (VPA) is an effective, widely used anticonvulsant in this patient population, but believed by some researchers to increase surgical bleeding because of quantitative thrombocytopenia and functional defects in platelet aggregation. Because we have observed no clinical evidence that perioperative administration of VPA increases blood loss or complications related to postoperative bleeding in patients undergoing temporal lobectomy at our institution, we sought to test this hypothesis. We made a retrospective review of the medical records of all patients who underwent epilepsy surgery at the University of California, San Francisco Medical Center, from September 1986 through January 1993. Patients who had a temporal lobectomy and whose medical records documented preoperative platelet counts and pre- and postoperative hematocrit and hemoglobin values were included. We excluded patients who had cranial surgery before temporal lobectomy and those with intracranial neoplasms or vascular malformations. Patients were divided into two groups: those who received VPA in the immediate preoperative period and those who had not received VPA recently. We compared the estimated surgical blood loss and the estimated change in red blood cell (RBC) volume between groups by unpaired t tests. The charts of 87 consecutive patients qualified for inclusion in the study. Patients in the VPA group had relative (but not absolute) thrombocytopenia preoperatively (235 +/- 64 vs. 277 +/- 69 k in the No-VPA group). There were no differences in the estimated blood loss, RBC volume, or in the incidence of postoperative transfusion. VPA apparently does not increase complications of hemostasis during therapeutic surgical resections for epilepsy. Therefore, we do not recommend routinely discontinuing VPA before craniotomy.

Object Trigeminal neuralgia (TN) is characterized by paroxysmal lancinating pain in the trigeminal nerve distribution. When TN is refractory to medical management, patients are referred for microvascular decompression (MVD), radiofrequency ablation, or radiosurgery. After the initial treatment, patients may have refractory or recurrent symptoms requiring retreatment. The purpose of this study was to determine what factors are associated with the need for retreatment and which modality is most effective. Methods To define this population further, the authors evaluated a cohort of patients who required retreatment for TN. The mean follow-up periods were 51 months from the first treatment and 23 months from the last one, and these were comparable among treatment groups. Conclusions Trigeminal neuralgia can recur after neurosurgical treatment. In this study the authors demonstrate that the number of patients requiring retreatment is not negligible. Lower retreatment rates were seen in patients who initially underwent radiosurgery, compared with those in whom MVD or radiofrequency ablation were performed. Radiosurgery was more likely to be the final treatment for recurrent TN regardless of the initial treatment. After retreatment, the majority of patients attained complete or very good pain relief. Pain relief after retreatment correlates with postoperative facial numbness.

Purpose To assess outcomes of language, verbal memory, cognitive efficiency and mental flexibility, mood, and quality of life (QOL) in a prospective, multicenter pilot study of Gamma Knife radiosurgery (RS) for mesial temporal lobe epilepsy (MTLE). Methods RS, randomized to 20 Gy or 24 Gy comprising 5.5-7.5mL at the 50% isodose volume, was performed on mesial temporal structures of patients with unilateral MTLE. Neuropsychological evaluations were performed at preoperative baseline, and mean change scores were described at 12 and 24 months postoperatively. QOL data were also available at 36 months. Key Findings 30 patients were treated and 26 were available for the final 24 month neuropsychological evaluation. Neither language (Boston Naming Test), verbal memory (California Verbal Learning Test and Logical Memory subtest of the Wechsler Memory Scale-Revised), cognitive efficiency and mental flexibility (Trail Making Test), nor mood (Beck Depression Inventory) differed from baseline. QOL scores improved at 24 and 36 months, with those patients attaining seizure remission by month 24 accounting for the majority of the improvement. Significance The serial changes in cognitive outcomes, mood, and QOL are unremarkable following RS for MTLE. RS may provide an alternative to open surgery especially in those patients at risk of cognitive impairment or who desire a noninvasive alternative to open surgery.

Object Trigeminal neuralgia (TN) is a painful disorder that frequently causes lancinating, electrical shock–like pain in the trigeminal distribution. Common surgical treatments include microvascular decompression (MVD), radio-surgery, and radiofrequency ablation, and complete pain relief is generally achieved with a single treatment in 70 to 85% of cases for all modalities. In a subset of patients with multiple sclerosis (MS), however, the rates of surgical treatment failure and the need for additional procedures are significantly increased compared with those in patients without MS. In this study the authors report their experience with a cohort of 11 patients with TN who also had MS, and assess the efficacy of MVD, gamma knife surgery (GKS), and radiofrequency ablation in achieving complete or partial long-term pain relief. Methods Eleven patients with TN and MS who were treated by the senior author (N.B.) at the University of California, San Francisco were included in this study. All patients underwent GKS and/or radiofrequency ablation, and four received MVD. A detailed clinical history and intraoperative findings were recorded for each patient and frequent follow-up evaluations were performed, with a mean follow-up duration of 40.6 months (range 1–96 months). Pain was assessed for each patient by using the Barrow Neurological Institute scale (Scores I–V). Conclusions Achieving complete pain relief in patients with TN and MS required significantly more treatments compared with all other patients with TN who did not have MS (p = 0.004). Even when compared with a group of 32 patients who had highly refractory TN, the cohort with MS required significantly more treatments (p = 0.05). Radiosurgery proved to be an effective procedure and resulted in fewer retreatments and longer pain-free intervals compared with MVD or radiofrequency ablation.