Randomized controlled trial of 2.5-cm versus 3.5-cm mesial temporal resection in temporal lobe epilepsy—part 1: intent-to-treat analysis

Schramm, Johannes; Lehmann, Thomas‐Nicolas; Zentner, Josef; Mueller, Christian A.; Scorzin, Jasmin; Fimmers, Rolf; Meencke, Heinz-Joachim; Schulze‐Bonhage, Andreas; Elger, Christian E.

doi:10.1007/s00701-010-0900-6

Cited by 65 publications

(41 citation statements)

References 36 publications

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“…37,51,64,81,82,84,85 In the remaining one-third of patients, seizures usually recur during the first postoperative year, 37,48,97 although the percentage of patients who remain seizure free may decline with longer follow-up, with reported rates as low as 53% for patients with at least 5 years of follow-up and 41% for 10 years. 3,7,28,30,48,64,90 Recent data suggest that the histopathological abnormalities underlying surgically treated drug-resistant MTLE are the main factor predictive of seizure outcome.…”

Section: Discussionmentioning

confidence: 99%

Seizure outcome in surgically treated drug-resistant mesial temporal lobe epilepsy based on the recent histopathological classifications

Giulioni¹,

Marucci

Martinoni³

et al. 2013

JNS

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D rug-resistant MTLE is the most common type of epilepsy requiring surgical treatment, with a favorable seizure outcome being achieved in about 60%-75% of patients. 50,51,64,82,89 Clinically, MTLE is often regarded as a relatively homogeneous syndromic entity, with seizures characterized by typical ictal semiology 32,96 and EEG findings. 29,96 However, a variety of MTLE subtypes have been described according to the underlying etiology, with different surgical prognoses. 47,89,92 Recent neuropathological classifications of epi lep to gen ic lesions, such as mesial temporal sclerosis (MTS), 11 granule cell pathology (GCP), 10 focal cortical dysplasia (FCD), 12 and epilepsy-associated low-grade tumor (ELGT) 1,54,55,73,74,91 Object. The study was performed to investigate the relation between seizure outcome after surgical treatment of mesial temporal lobe epilepsy (MTLE) and pathological findings, classified according to the recently proposed classifications of mesial temporal sclerosis (MTS), granule cell pathology (GCP), focal cortical dysplasia (FCD) and epilepsy-associated low-grade tumors (ELGT).Methods. The authors analyzed data obtained in 120 consecutive cases involving patients presenting with drugresistant MTLE, who underwent tailored anteromesial temporal lobe resection, and correlated seizure outcome with pathological findings. They identified 5 histopathological groups: Group 1-ELGT, alone or associated with other lesions (30 cases); Group 2-isolated FCD (17 cases); Group 3-MTS, with or without GCP (28 cases); Group 4-MTS associated with FCD, with or without GCP (37 cases); Group 5-other lesions (8 cases).Results. Engel Class I outcome was observed in 83% of patients with ELGT (Class IA in 63%); in 59% of patients with isolated FCD, with FCD Type II showing a better prognosis than FCD Type I; in 82% of patients with isolated MTS (Class IA in 50%), with MTS Type 1a and MTS Type 1b showing a better prognosis than MTS Type 2 and patients with MTS and GCP having better postsurgical results than those with MTS without GCP. Engel Class I outcome was also achieved in 84% of patients with FCD associated with MTS (Engel Class IA in 62%); also in this group MTS 1a and MTS 1b associated with FCD showed a better prognosis than FCD associated with MTS 2. Finally, Engel Class I was also achieved in 2 patients with vascular malformation and in 1 with a temporal pole encephalocele.Conclusions. Patients with MTLE and ELGT, MTS, or MTS associated with FCD showed the best postsurgical seizure outcome (Engel Class I in more than 80% of cases), whereas only 63% of patients with isolated FCD achieved the same type of outcome. Interestingly, the analysis of seizure outcome in histopathological subtypes of FCD and of MTS showed different prognoses in the different pathological subgroups, with worse outcomes for atypical MTS, absence of GCP, and isolated FCD Type I. 37Abbreviations used in this paper: EEG = electroencephalographic; ELGT = epilepsy-associated low-grade tumor; FCD = focal cortical dysplasia; GCP = granule cell ...

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Section: Discussionmentioning

confidence: 99%

Seizure outcome in surgically treated drug-resistant mesial temporal lobe epilepsy based on the recent histopathological classifications

Giulioni¹,

Marucci

Martinoni³

et al. 2013

JNS

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“…The risk of relapse was less than 2% in patients who were seizure free during the initial 2 years after surgery. 28,56 centers found factors predicting seizure freedom after surgery for MTS: extent of resection, shorter duration of epilepsy, younger age at surgery, absent history of status epilepticus, absent secondary generalization, lack of temporal neocortical, extratemporal, or contralateral temporal EEG activity, presence of lateralized memory deficits, younger age at time of surgery, and concordance of primary study results (such as MRI and EEG). The various methodologies used in these studies may partially explain the differing results.…”

Section: Seizure Freedom Over Time After Surgery For Mtsmentioning

confidence: 96%

“…[1][2][3]5,7,[10][11][12]14,15,19,28,29,31,32,37,[46][47][48]50,52,56,57,63,64,66,73,74 Studies varied with inclusion of imaging-defined and/or pathologically diagnosed MTS, the type and timing of the seizure outcome analyses, and the definitions used for seizure freedom. Rates of seizure freedom decrease with longer follow-up.…”

Section: Seizure Freedom Over Time After Surgery For Mtsmentioning

confidence: 99%

Anterior temporal lobectomy with amygdalohippocampectomy for mesial temporal sclerosis: predictors of long-term seizure control

Elliott¹,

Bollo

Berliner³

et al. 2013

JNS

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Object In this paper the authors' goal was to identify preoperative variables that predict long-term seizure freedom among patients with mesial temporal sclerosis (MTS) after single-stage anterior temporal lobectomy and amygdalohippocampectomy (ATL-AH). Methods The authors retrospectively reviewed 116 consecutive patients (66 females, mean age at surgery 40.7 years) with refractory seizures and pathologically confirmed MTS who underwent ATL-AH with at least 2 years of follow-up. All patients underwent preoperative MRI and video-electroencephalography (EEG); 106 patients (91.4%) underwent Wada testing and 107 patients (92.2%) had neuropsychological evaluations. The authors assessed the concordance of these 4 studies (defined as test consistent with the side of eventual surgery) and analyzed the impact of preoperative variables on seizure freedom. Results The median follow-up after surgery was 6.7 years (mean 6.9 years). Overall, 103 patients (89%) were seizure free, and 109 patients (94%) had Engel Class I or II outcome. Concordant findings were highest for video-EEG (100%), PET (100%), MRI (99.0%), and Wada testing (90.4%) and lowest for SPECT (84.6%) and neuropsychological testing (82.5%). Using binary logistic regression analysis (seizure free or not) and Cox proportional hazard analysis (seizure-free survival), less disparity in the Wada memory scores between the ipsilateral and contralateral sides was associated with persistent seizures. Conclusions Seizure freedom of nearly 90% can be achieved with ATL-AH in properly selected patients with MTS and concordant preoperative studies. The low number of poor outcomes and exclusion of multistage patients limit the statistical power to determine preoperative variables that predict failure. Strong Wada memory lateralization was associated with excellent long-term outcome and adds important localization information to structural and neurophysiological data in predicting outcome after ATL-AH for MTS.

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“…These include the RCT by Wiebe et al3 the most highly cited epilepsy surgery RCT, and, most recently, the ERSET (Early Randomized Surgical Epilepsy Trial) study by Engel et al4 in patients with new‐onset drug‐resistant epilepsy (within 2 years of becoming drug‐resistant). Four RCTs compared small to larger surgical resections, including temporal lobectomy with or without sparing of the superior temporal gyrus,23 2.5‐ versus 3.5‐cm temporal resection,24 temporal lobectomy with partial versus complete hippocampectomy25 and temporal lobectomy with or without anterior corpus callosotomy in patients with developmental delay only 26. Finally, one RCT compared two surgical approaches for selective amygdalohippocampectomy (SAH), that is, the transsylvian versus the transcortical approach 27…”

Section: The Evidence For Resective Surgerymentioning

confidence: 99%

“…Other challenges include the significant heterogeneity that exists among patients in regard to age of onset, epilepsy duration, and epilepsy etiology 29. The five resective epilepsy surgery RCTs also have limited generalizability because they include only patients with TLE, often mesial TLE only, as in the Schramm et al and the ERSET studies 4, 24. In addition, recruitment processes and the lengthy baseline testing for the ERSET study resulted in slow patient accrual, with only 38 of the planned 200 patients recruited, precluding meaningful conclusions about certain outcomes (e.g., neuropsychological outcomes) 30.…”

Section: The Evidence For Resective Surgerymentioning

confidence: 99%

Not all that glitters is gold: A guide to surgical trials in epilepsy

Jehi

2016

Epilepsia Open

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SummaryEpilepsy surgery is often the only effective treatment in appropriately selected patients with drug‐resistant epilepsy, a disease affecting about 30% of those with epilepsy. We review the evidence supporting the use of epilepsy surgery, with a focus on randomized controlled trials (RCTs). Second, we identify gaps in knowledge about the benefits of epilepsy surgery for certain populations, the challenges of individualizing the choice of surgery, and our lack of understanding of the mechanisms of surgical outcomes. We conducted a search (MEDLINE, Embase, Cochrane, Clinicaltrials.gov) on March 2, 2016, to identify epilepsy surgery RCTs, systematic reviews, or health technology assessments (HTAs). Abstracts were screened to identify resective, palliative (e.g., corpus callosotomy, multiple subpial transection [MST]), ablative (e.g., Laser interstitial thermal therapy [LITT], gamma knife radiosurgery [RS]), and neuromodulation (e.g., cerebellar stimulation [CS], hippocampal stimulation [HS], repetitive transcranial magnetic stimulation [rTMS], responsive neurostimulation [RNS], thalamic stimulation [TS], trigeminal nerve stimulation [TNS], and vagal nerve stimulation [VNS]) RCTs. Study characteristics and outcomes were extracted. Knowledge gaps were identified. Of 1,205 abstracts, 20 RCTs were identified (resective surgery including corpus callosotomy [n = 7], MST [n = 0], RS [n = 1, 3 papers], LITT [n = 0], CS [n = 1], HS [n = 2], RNS [n = 1], rTMS [n = 1], TNS [n = 1], TS [n = 1], and VNS [n = 5]). Most studies targeted patients with temporal lobe epilepsy (TLE) and none examined the effectiveness of resective surgical therapies in patients with extra‐TLE (ETLE) or with specific lesions aside from mesial temporal lobe sclerosis. No pediatric surgical RCTs were identified except for VNS. Few RCTs address the effectiveness of surgery in epilepsy and most are of limited generalizability. Future studies are needed to compare the effectiveness of different surgical strategies, better understand the mechanisms of surgical outcomes, and define the ideal surgical approaches, particularly for patients with high or very low cognitive function, normal imaging, or ETLE.

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Randomized controlled trial of 2.5-cm versus 3.5-cm mesial temporal resection in temporal lobe epilepsy—part 1: intent-to-treat analysis

Abstract: The primary intent-to-treat analysis did not show a different seizure freedom rate for the more posteriorly reaching 3.5-cm resection group. It appears possible that not maximal volume resection but adequate volume resection leads to good seizure freedom.

Cited by 65 publications

References 36 publications

Seizure outcome in surgically treated drug-resistant mesial temporal lobe epilepsy based on the recent histopathological classifications

Seizure outcome in surgically treated drug-resistant mesial temporal lobe epilepsy based on the recent histopathological classifications

Anterior temporal lobectomy with amygdalohippocampectomy for mesial temporal sclerosis: predictors of long-term seizure control

Not all that glitters is gold: A guide to surgical trials in epilepsy

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