Apical temporal lobe resection; “tailored” hippocampus-sparing resection based on presurgical evaluation data

SUMMARYPurpose: The new International League Against Epilepsy (ILAE) classification for focal cortical dysplasia (FCD) differentiates between patients with isolated FCD (type 1) and FCD with an associated hippocampal sclerosis (HS) (type 3a). In contrast to the former FCD classification by Palmini, which considered only histologic features, the novel ILAE classification also relies on magnetic resonance imaging (MRI) findings and presumed pathogenesis. We investigated in a cohort of 100 patients with exclusively temporal FCD if the new subdivision of FCD is reflected in clinical characteristics. Methods: Thirty-one patients with FCD type 1 and 50 patients with FCD type 3a in the temporal lobe were included. In all patients MRI and histology of the FCD were available. Both patient groups were compared to 19 patients with temporal FCD type 2 with clearly different histologic appearance. Key Findings: Patients with FCD type 1 and type 3a presented with similar clinical features in many respects. In univariate analyses, no statistically significant differences were found as to age at epilepsy onset (p = 0.07) and epilepsy surgery (p = 0.14), a normal appearing neocortical temporal lobe (p = 0.08) or diagnosis of FCD by visual inspection of MRI (p = 0.08), preoperative seizure frequency (p = 0.06), and the predominance of an epigastric aura (p = 0.08). The postoperative outcome was nearly identical 1 year (p = 0.8) and 2 (p = 0.8), 3 (p = 0.8), 5 (p = 0.7), and 8 (p = 1.0) years postoperatively. Only febrile seizures (p = 0.025) and an aura (p = 0.03) were significantly more frequently reported in patients with FCD type 3a. Similar results were obtained from a multivariate logistic regression analysis. Patients with FCD type 2 were more different: Compared to FCD type 3a, age at epilepsy surgery was significantly lower (p = 0.004) and auras (p = 0.005) were significantly less frequently reported. Epigastric auras (p = 0.04) and febrile seizures (p = 0.025) occurred significantly less frequently in patients with FCD type 2 without HS compared to FCD type 3a. The diagnosis of an FCD was significantly more frequently made (p = 0.03) by visual inspection of the MRI compared to FCD type 1. Significance: Clinical features did not allow to clear separation of temporal FCD types 1 and 3a. Statistically significant differences were seen in a history of febrile seizures and the occurrence of auras more common in FCD type 3a. However, FCD type 2 in the same localization but with different histology presented with further differences such as more frequent FCD diagnosis by visual inspection of MRI, earlier operation, and less frequent epigastric auras.

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“…In addition, Elsharkawy et al. () showed that apical temporal lobe hippocampus‐sparing resections can be successful in patients with FCD.…”

Section: Discussionmentioning

confidence: 99%

Is there evidence for clinical differences related to the new classification of temporal lobe cortical dysplasia?

et al. 2013

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“…Across environmental variables, obstetrical complications are one of the strongest predictors of risk for schizophrenia (67–70). There is persuasive evidence to suggest that obstetrical complications, particularly perinatal hypoxia and prenatal infections, are related to smaller hippocampal volumes in schizophrenia (71, 72). Furthermore, in animal models, prenatal- and birth-related hypoxic insults have been demonstrated to result in hippocampal neuron damage and a reduction in hippocampal cell number (73, 74).…”

Section: Discussionmentioning

confidence: 99%

Hippocampal Volume Development in Healthy Siblings of Childhood-Onset Schizophrenia Patients

Mattai¹,

Hosanagar²,

Weisinger³

et al. 2011

AJP

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Objective Previous anatomic studies have established a reduction in hippocampal volume in schizophrenia, but few have investigated the progressive course of these changes and whether they are trait markers. In the present study, the authors examined hippocampal volumes in relation to age for patients with childhood-onset schizophrenia, their nonpsychotic healthy siblings, and healthy comparison subjects. Method Anatomic brain magnetic resonance scans were obtained in childhood-onset schizophrenia probands (N=89, 198 scans), their nonpsychotic full siblings (N=78, 172 scans), and matched healthy comparison subjects (N=79, 198 scans) between the ages of 10 and 29 years. Total, left, and right hippocampal volumes were measured using FreeSurfer software and analyzed using a linear mixed-model regression covarying for sex and intracranial volume. Results Childhood-onset schizophrenia probands had a fixed reduction in hippocampal volumes (total, left, and right) relative to both nonpsychotic siblings and healthy comparison subjects, whereas there were no significant volumetric or trajectory differences between nonpsychotic siblings and healthy comparison subjects. Conclusions Fixed hippocampal volume loss seen in childhood-onset schizophrenia, which is not shared by healthy siblings, appears to be related to the illness. Decreased hippocampal volume is not strong ly genetically related but represents an important intermediate disease phenotype.

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“…The anteromedial two-thirds of the temporal lobe were resected in almost all patients with MTS. Patients with temporo-apical lesions sparing the hippocampus received an apical temporal lobe resection without removal of the hippocampus but including the amygdala 22. Patients with DH pathologies underwent hemispherectomy in one of its modern ‘functional’, that is, partly disconnective variants, mainly by removal of the anterior temporal lobe and insular cortex and sectioning of the corpus callosum.…”

Section: Methodsmentioning

confidence: 99%

Trends in epilepsy surgery: stable surgical numbers despite increasing presurgical volumes

Cloppenborg

May

Blümcke³

et al. 2016

J Neurol Neurosurg Psychiatry

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120

116

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Introduction Despite the success of epilepsy surgery, recent reports suggest a decline in surgical numbers. We tested these trends in our cohort to elucidate potential reasons. Patients and methods Presurgical, surgical and postsurgical data of all patients undergoing presurgical evaluation in between 1990 and 2013 were retrospectively analysed. Patients were grouped according to the underlying pathology. Results A total of 3060 patients were presurgically studied, and resective surgery was performed in 66.8% (n=2044) of them: medial temporal sclerosis (MTS): n=675, 33.0%; benign tumour (BT): n=408, 20.0%; and focal cortical dysplasia (FCD): n=284, 13.9%. Of these, 1929 patients (94.4%) had a follow-up of 2 years, and 50.8% were completely seizure free (Engel IA). Seizure freedom rate slightly improved over time. Presurgical evaluations continuously increased, whereas surgical interventions did not. Numbers for MTS, BT and temporal lobe resections decreased since 2009. The number of non-lesional patients and the need for intracranial recordings increased. More evaluated patients did not undergo surgery (more than 50% in 2010-2013) because patients were not suitable (mainly due to missing hypothesis:

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Apical temporal lobe resection; “tailored” hippocampus-sparing resection based on presurgical evaluation data

Abstract: Apical temporal resection sparing the mesial temporal structures is an effective procedure with good long-term seizure outcome in patients with refractory epilepsy due to lesions confined to the apex of the temporal lobe.

Cited by 23 publications

References 41 publications

Is there evidence for clinical differences related to the new classification of temporal lobe cortical dysplasia?

Is there evidence for clinical differences related to the new classification of temporal lobe cortical dysplasia?

Hippocampal Volume Development in Healthy Siblings of Childhood-Onset Schizophrenia Patients

Trends in epilepsy surgery: stable surgical numbers despite increasing presurgical volumes

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