Epilepsy surgery of the rolandic and immediate perirolandic cortex: Surgical outcome and prognostic factors

Abstract

Dr. Delev is resident at the Department of Neurosurgery (University Clinic of Bonn) with special interest in epilepsy surgery. SUMMARYObjective: Herein we present a single-center retrospective study of patients who underwent epilepsy surgery for seizures arising from the sensorimotor (rolandic) cortex. The goal was to find prognostic factors associated with better seizure outcome and to evaluate both surgical and neurologic outcomes. Patients, methods, and materials: A total of 66 patients fulfilled eligibility criteria and were included in the study. Patients were divided into two groups for analysis: patients with resections within rolandic cortex (RO group; n = 46), and patients with resections in immediate perirolandic cortex and simultaneous sensorimotor multiple subpial transections (IPR group; n = 20). Results: Favorable postoperative seizure outcome (International League Against Epilepsy [ILAE]; ILAE1-ILAE3) was achieved in 42 patients (64%), 39 (59%) of whom were completely seizure-free (ILAE1). The favorable seizure outcome in the RO group (72%) was better than in the IPR group (45%) (p = 0.04, relative risk [RR] 0.51 [0.28-0.94, 95% CI]). Eighteen patients (34%) had a postoperative permanent neurologic deficit. Independent predictors for excellent seizure outcome (ILAE1) after multivariate regression analysis were complete resection of the lesion (p < 0.001), pathology (p = 0.009), age at surgery (p = 0.03), and the absence of preoperative simple partial seizures (p = 0.01). Significance: With a 64% favorable seizure outcome, surgery for intractable epilepsy arising from sensorimotor cortex is possible and can be worthwhile. The increased risk for postoperative neurologic deficits is higher than in other locations, and this must be discussed with patients in detail prior to surgery. Best postoperative results can be achieved in cases in which a complete resection is possible without damaging eloquent cortical areas. KEY WORDS: Perirolandic, Rolandic cortex, Epilepsy, Surgery.Intractable epilepsy is a major health problem resulting in cognitive and neuropsychological impairment and diminished quality of life. Surgery is a safe and well-accepted treatment option with proven better results than drug treatment for intractable mesial temporal lobe epilepsy (MTLE).1 However, about 30% of cases of drug-resistant epilepsy show lesions outside the temporal lobe.2 The surgical treatment of these extratemporal lobe epilepsies (ETLEs) is more complex for both epileptologists and neurosurgeons.

Surgery in patients with childhood-onset epilepsy: analysis of complications and predictive risk factors for a severely complicated course

“…An increased risk of major neurological complications has been described after surgery within or around eloquent areas 22. A recent series described 18 out of 66 patients (34%) who developed a new sensorimotor deficit after surgery for seizures arising from the rolandic/perirolandic region,24 with similar or even worst results having been reported by previous studies 25–28. In our patients operated on in or around the rolandic region, a SCC was detected in 18.2% of cases, a proportion that compares favourably with previous reports.…”

Epilepsy surgery near or in eloquent cortex in children—Practice patterns and recommendations for minimizing and reporting deficits

“…Vascular lesions and discrete tumors are generally treated without including surrounding EC, whereas focal cortical dysplasia (FCD) lesions appear to be the strongest justification for extending resections to include functional abnormalities involving EC. Unfortunately, however, this etiologic substrate has one of the lowest rates of seizure freedom following complete resections and is thus most likely to experience category IV outcomes up to rates approaching 50% . For type IIb dysplasia, complete cortical resection (but not necessarily resection of the subcortical trans mantle tail) appears to be required for seizure freedom …”

“…Nonetheless, significant subjectivity exists on how tests are used to define the EZ and EC, which areas are considered to be “critical” function, notions of plasticity and influence of age, and what defines a complete resection of the perceived EZ. Although some centers are conservative and favor a smaller albeit “incomplete” resection to preserve eloquent function, “complete” resections of the EZ are believed to achieve higher rates of seizure freedom and can prompt aggressive resection of EC …”

“…Nonetheless, significant subjectivity exists on how tests are used to define the EZ and EC, which areas are considered to be "critical" function, notions of plasticity and influence of age, and what defines a complete resection of the perceived EZ. Although some centers are conservative and favor a smaller albeit "incomplete" resection to preserve eloquent function, [2][3][4] "complete" resections of the EZ are believed to achieve higher rates of seizure freedom and can prompt aggressive resection of EC. 5 Most surgical series report outcomes with respect to seizure control, but the deficits incurred are generally not completely documented, [6][7][8][9][10][11][12][13][14][15][16] a consideration particularly relevant for the subset of patients in whom the EZ is close to or involves the EC.…”

The role of intraoperative MRI in resective epilepsy surgery for peri-eloquent cortex cortical dysplasias and heterotopias in pediatric patients

“…9,28 Traditionally, aggressive resections in the peri-eloquent regions have been tempered by high rates of neurological deficit, and seizure-free rates in pediatric patients following surgery range from 43% to 64%. 1,2,8,24 Intraoperative identification of the extent of resection with compensation for brain shift is a critical factor in perieloquent resections, which has been shown to be aided by intraoperative MRI (iMRI).…”