Psychogenic nonepileptic seizures in patients with surgically treated temporal lobe epilepsy: Presurgical and de novo postsurgical occurrence

Whether occurring before or after an epilepsy surgery, psychogenic nonepileptic seizures (PNES) impact treatment options and quality of life of patients with epilepsy. We investigated the frequency of pre- and postsurgical PNES, and the postsurgical Engel and psychiatric outcomes in patients with drug-resistant temporal lobe epilepsy (TLE). We reviewed 278 patients with mean age at surgery of 37.1 ± 12.4 years. Postsurgical follow-up information was available in 220 patients, with average follow-up of 4 years.Nine patients (9/278 or 3.2%) had presurgical documented PNES. Eight patients (8/220 or 3.6%) developed de novo PNES after surgery. Pre- and postsurgery psychiatric comorbidities were similar to the patients without PNES. After surgery, in the group with presurgical PNES, five patients were seizure-free, and three presented persistent PNES. In the group with de novo postsurgery PNES, 62.5% had Engel II–IV, and 37.5% had Engel I. All presented PNES at last follow-up.Presurgical video-EEG monitoring is crucial in the diagnosis of coexisting PNES. Patients presenting presurgical PNES and drug-resistant TLE should not be denied surgery based on this comorbidity, as they can have good postsurgical epilepsy and psychiatric outcomes. Psychogenic nonepileptic seizures may appear after TLE surgery in a low but noteworthy proportion of patients regardless of the Engel outcome.     

Safety of video-EEG monitoring and surgical outcome in patients with mesial temporal sclerosis and psychosis of epilepsy

PurposeCortico-amygdalohippocampectomy (CAH) has become an important treatment option for patients with refractory temporal lobe epilepsy and mesial temporal sclerosis (TLE-MTS); it has resulted in a 60–70% seizure remission rate and significant quality of life (QOL) improvements. Video-electroencephalography (VEEG) monitoring has been widely used in epilepsy centers for pre-surgical evaluation. A major concern in epilepsy surgery is whether to consider CAH treatment in patients with psychosis of epilepsy (POE). This study analyzed the safety and adverse events (AEs) of VEEG monitoring and the post-surgical outcomes of patients with refractory TLE-MTS and POE who underwent CAH.MethodClinical, sociodemographic and VEEG data from 18 patients with TLE-MTS and POE were analyzed. Psychiatric evaluations were performed using DSM-IV and ILAE criteria. The seizure outcome was evaluated using Engel's criteria.ResultsTwo patients (11.2%) presented AEs that did not result in increased lengths of hospitalization. Of the 10 patients (55.5%) who underwent CAH, 6 (60%) became free of disabling seizures (Engel I). The psychiatric and QOL evaluations revealed improvements of psychotic symptoms (p = 0.01) and in Physical Health (p = 0.01) following surgery.ConclusionThese data reinforce that VEEG monitoring is a safe method to evaluate patients with refractory TLE-MTS and POE in epilepsy centers.     

Major depressive disorder as a predictor of a worse seizure outcome one year after surgery in patients with temporal lobe epilepsy and mesial temporal sclerosis

PurposeThe association between pre-surgical psychiatric disorders (PDs) and worse seizure outcome in patients with refractory epilepsy submitted to surgery has been increasingly recognized in the literature. The present study aimed to verify the impact of pre- and post-surgical PD on seizure outcome in a series of patients with refractory temporal lobe epilepsy and mesial temporal sclerosis (TLE–MTS).MethodData from 115 TLE–MTS patients (65 females; 56.5%) who underwent cortico-amygdalohippocampectomy (CAH) were analyzed. Pre- and post-surgical psychiatric evaluations were performed using DSM-IV and ILAE criteria. The outcome subcategory Engel IA was considered as corresponding to a favorable prognosis. A multivariate logistic regression model was applied to identify possible risk factors associated with a worse seizure outcome.ResultsPre-surgical PDs, particularly major depressive disorder (MDD), anxiety and psychotic disorders, were common, being found in 47 patients (40.8%). Fifty-six patients (48.7%) were classified as having achieved an Engel IA one year after CAH. According to the logistic regression model, the presence of pre-surgical MDD (OR = 5.23; p = 0.003) appeared as the most important risk factor associated with a non-favorable seizure outcome.ConclusionAlthough epilepsy surgery may be the best treatment option for patients with refractory TLE–MTS, our findings emphasize the importance of performing a detailed psychiatric examination as part of the pre-surgical evaluation protocol.     

Postsurgical outcome in patients with auditory auras and drug-resistant epilepsy

PurposeWe assessed whether patients with auditory auras have similar outcomes after epilepsy surgery as patients without auditory auras, and hypothesized that patients with non-dominant hemisphere foci might fare better after temporal lobe surgery than patients with dominant resections.MethodsIn this retrospective study, outcome after temporal resection was assessed for patients with drug-resistant epilepsy. Preoperative demographic data, clinical data, and surgical outcome were prospectively registered in a database from 1986 through 2016. Seizure outcome was classified as either seizure-free or relapsed.ResultsData were available in 1186 patients. Forty five patients (3.8%) reported auditory auras; 42 patients (93%) had temporal lobe epilepsy (TLE), and three patients (7%) had extratemporal epilepsy. Since most patients with auditory auras had TLE and in order to have comparable groups, we selected 41 patients with auditory auras and compared them with patients without auditory auras who had temporal lobe resections (767 patients). There were no significant demographic or clinical differences between TLE patients with auditory auras and those without. Patients who had auditory auras were more likely to relapse after temporal lobe surgery than those without (p = 0.03). Among patients who had auditory auras and temporal lobe surgery, side of surgery was not related to postoperative outcome (p = 0.3).ConclusionAuditory auras are rare among patients with drug-resistant TLE. The presence of an auditory aura in a patient with drug-resistant TLE carries a worse prognosis for a postoperative seizure free outcome and this is not related to the side of surgery.     

Prognostic significance of acute postoperative seizures in extra-temporal lobe epilepsy surgery

ObjectiveThis study aims to assess the prognostic value of acute postoperative seizures (APOS) in patients surgically treated for drug-resistant extra-temporal lobe (ET) epilepsy.MethodsWe studied 77 consecutive patients with ET epilepsy who underwent epilepsy surgery and were followed up for at least 2 years (mean duration of follow-up 6.2 years, range 2–14). Medical charts were reviewed to identify APOS, defined as ictal events with the exception of auras occurring within the first 7 days after surgery. Seizure outcome was determined at annual intervals. Patients who were in Engel Class I at the last contact were classified as having a favourable outcome.ResultsSeizure outcome was favourable in 47 patients (61%). The occurrence of APOS and incompleteness of resection were found to be independently associated with unfavourable outcome in a multiple regression model including all preoperative factors identified as outcome predictors in univariate analysis. Duration of illness was the only independent preoperative predictor of APOS.ConclusionsOur study suggests that APOS may predict long-term outcome in patients undergoing resective surgery for ET epilepsy. Given some study limitations, our findings should be regarded as preliminary and need confirmation from future larger, prospective, multicentre studies.SignificanceCaution may be required in the clinical management of patients experiencing APOS.     

Patient satisfaction with temporal lobectomy/selective amygdalohippocampectomy for temporal lobe epilepsy and its relationship with Engel classification and the side of lobectomy

PurposeThe aim of this study was to investigate not only the effectiveness of epilepsy surgery in improving seizure control but also patient satisfaction with the result of the procedure in a sample of patients operated on at a specialized epilepsy unit.MethodsPatients with temporal lobe epilepsy who had undergone epilepsy surgery (temporal lobectomy/amygdalohippocampectomy) were interviewed in a standardized telephone survey about their satisfaction with the results of the surgery. The morbidity of the surgery was also analyzed retrospectively. The initial study population consisted of 6 amygdalohippocampectomy and 102 temporal lobectomy patients and was reduced to a final sample consisting of 4 amygdalohippocampectomy and 67 lobectomy patients, as the other patients were not available for interview. Surgical results were based on the Engel classification, and satisfaction with the surgery was assessed by asking patients to rate their result and state whether they would make the same decision (to be operated on) again.ResultsA significant number of patients classified as Engel I or II, who considered the surgical outcome good or excellent, said they would have the surgery again (p < 0.001). Left temporal lobectomy patients whose results fell in the Engel III/IV bracket were less satisfied (p = 0.001) than right temporal lobectomy patients with the same Engel classifications (0.048). Left temporal lobectomy patients who were classified as Engel class III and IV were less likely to have the surgery again if they had the choice (p = 0.016).DiscussionPatient satisfaction with the results of epilepsy surgery may depend not only on achieving seizure control but also on the temporal lobe resected. Since worse results were associated with lower satisfaction rates only for left temporal resection patients, it is possible that the cognitive consequences of this procedure compound the worse surgical result, leading to decreased satisfaction.     

Changes in psychiatric comorbidity during early postsurgical period in patients operated for medically refractory epilepsy—A MINI-based follow-up study

PurposeThe purpose of this study was to assess axis-I DSM-IV psychiatric disorders in patients at baseline and 3 months after surgery for medically refractory temporal lobe epilepsy.MethodThe Mini International Neuropsychiatric Interview (MINI) and Quality of Life in Epilepsy Inventory-10 (QOLIE-10) were evaluated before and 3 months after surgery in 50 consecutive patients (21 females, 29 males) with medically refractory temporal lobe epilepsy (persistent seizures > 2/month, despite treatment with ≥ 2 appropriate drugs in adequate doses for ≥ 2 years) who underwent surgery [anterior temporal lobectomy with amygdalo-hippocampectomy (for mesial temporal sclerosis in 40), electrocorticography-guided lesionectomy (for other lesions in 10)].ResultsTwenty-six patients (52%) had an axis-I psychiatric disorder [26% depressive disorder, 28% anxiety disorder] at baseline, while 30 (60%) patients had an axis-I psychiatric disorder [28% depressive disorder, 28% anxiety disorder] at 3 months after surgery. Twenty percent developed a new psychiatric disorder, while 12% showed improvement postsurgery. Mean QOLIE-10 scores improved from 23.78 to 17.80 [24 (48%) patients showed ≥ 5-point improvement]. Thirty-four (68%) patients had no seizure, 6 (12%) had non-disabling seizures, while 2 (4%) had disabling seizures after surgery. High frequency of seizures prior to surgery (p < 0.038) and seizure occurrence after surgery (p < 0.055) predicted the presence of psychiatric disorders after surgery. No clinical characteristic could predict development of new psychiatric disorder after surgery.ConclusionPsychiatric dysfunction in the early postsurgery period is seen in nearly half of patients undergoing surgery for temporal lobe epilepsy, is mild in nature, and does not adversely affect quality of life but may cause significant clinical problems when it arises de novo postsurgery.     

Surgical treatment of temporal lobe epilepsy with interictal psychosis: results of six cases

We describe the postsurgical outcome of six patients with medically intractable temporal lobe epilepsy and interictal psychosis who underwent temporal lobe resection. All patients were submitted to a comprehensive presurgical investigation, including prolonged video-EEG monitoring. Despite their psychotic disorders, all patients were able to provide informed consent and we were able to complete the investigation of all cases. Surgical complications occurred in two cases. Seizure outcome was Engel class I (free from incapacitating seizures) in all except one patient. There was no worsening of their psychoses. Until now, there has been relative improvement in the mental conditions of five patients. Although psychosis has been considered by some authors as a contraindication to epilepsy surgery, with appropriate psychiatric intervention, patients with refractory epilepsy and chronic interictal psychosis may be submitted to prolonged presurgical investigation and undergo surgery successfully.     

Invasive explorations in children younger than 3years

PurposeIn children with drug-resistant focal epilepsy who are candidates for surgery, invasive exploration is sometimes required. However, this is being controversially discussed for children younger than 3 years. The question of its necessity, feasibility and its risks is often raised, since it concerns primarily lesional epilepsy and a lesionectomy might be proposed right away. However, this attitude does not take into account the specificities of epilepsy at this age, including poor specificity of electroclinical semiology and the ongoing myelination challenging the interpretation of magnetic resonance imaging (MRI).MethodsWe retrospectively studied the records of children with drug-resistant epilepsy who were younger than 3 years of age at the time of their invasive exploration at our institution from 2000 to 2009. We reviewed the clinical, imaging and electrophysiological data, and included post-operative outcome for those who underwent surgery.Key findings26 Children met the inclusion criteria. All had drug-resistant epilepsy that started at an average of 5.2 months (range 0–20 months) with multiple daily seizures in all and developmental delay in 16. The average age at the time of exploration was 21.8 months (range 5–35). In 20 children, subdural electrodes in combination with two or three depth electrodes were implanted, and in six children aged over 2 years a stereo-electro-encephalography (SEEG) was performed. SEEG was considered technically difficult to achieve before the age of 2 years. The tolerance of invasive exploration was good with a 3% morbidity consisting of one subdural hematoma during exploration by subdural electrodes, evacuated without any particular sequelae. In 25 patients, the exploration permitted to propose a focal resection. The surgical intervention was in the frontal lobe in 12 cases, the parietal lobe in six, the occipital lobe in two patients, and the temporal lobe in one child who underwent an additional resection. Four children had a resection of two or three lobes. Five underwent a second surgery, following a second invasive exploration. Histologically, the resected tissue revealed focal cortical dysplasia in 21 cases (including three patients with tuberous sclerosis), two post-ischemic lesions, one dysembryoplastic neuroepithelial tumor, and one gangliglioma associated with dysplasia. The mean postoperative follow-up period was 51 months (range 4–110). For the children operated on twice, follow-up was counted from the second surgery on. Seventeen children (68%) had an outcome of Engel class 1. In five (20%), seizure frequency was significantly improved (Engel class 3). In two of three patients without improvement in seizure frequency (Engel class 4), a new SEEG is planned and the third is presently a candidate for hemispherotomy.SignificanceInvasive exploration is feasible, well tolerated and carries a low morbidity in children under 3 years of age. At this age, it is indicated for drug-resistant lesional epilepsy associated with developmental delay. It permits delineating the lesion, which is not possible with MRI. The choice of the technique is in part age-dependent. The discussion of its indication arises in the same way as in the older child.     

Psychosis after epilepsy surgery: Report of three cases

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.     

Psychosis after epilepsy surgery: report of three cases

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.     

Postsurgical outcome in patients with olfactory auras and drug-resistant epilepsy

ObjectivesWe investigated the clinical features associated with olfactory auras in patients with drug-resistant epilepsy and also hypothesized that this type of aura may predict worse postsurgical outcome in patients with drug-resistant temporal lobe epilepsy (TLE).MethodsIn this retrospective analysis, data from all patients with drug-resistant epilepsy who underwent epilepsy surgery were reviewed. Patients were prospectively registered in a database from 1986 through 2016. We assessed outcome in the first 5 years after surgery to produce a Kaplan–Meier estimate of seizure recurrence. Post-surgical outcome was classified into two groups; 1) seizure-free, with or without auras; or 2) relapse of complex partial or secondarily generalized seizures. We also investigated the clinical features of patients with TLE and olfactory auras compared with those without olfactory auras.ResultsWe studied 1186 patients. Thirty-seven patients (3.1%) reported olfactory auras with their seizures. Thirty-two patients had temporal lobe surgery. Intracranial video-EEG recording was performed in four patients. Three patients with lateral temporal neocortical seizures reported olfactory auras with their seizures; two of them were seizure-free after surgery. There were no significant clinical differences between patients with TLE and olfactory auras compared with those without. Seizure outcome after surgery was not significantly different between these two groups (p = 0.3; Cox–Mantel test).ConclusionThe rarity of olfactory auras makes it difficult to propose new diagnostic and treatment strategies. A multicenter approach, which can enroll more patients, is needed to devise better therapies for patients with drug-resistant epilepsy and this symptom.     

The duration of temporal lobe epilepsy and seizure outcome after epilepsy surgery

To assess the effect of the duration of epilepsy on the outcome of epilepsy surgery in non-lesional medically refractory temporal lobe epilepsy we reviewed the outcome of 76 patients.MethodsAll patients had anterior temporal resections for “non-lesional” temporal epilepsy (excluding any patient with tumours or vascular malformations but including patients with hippocampal sclerosis). Outcome at one year was assessed using Engel's scale.Results67% had a good outcome (Engel I or II). The mean duration of epilepsy was 23.0 years (range 2.9–46.9 years). Overall, there was no significant difference between patients with good outcome (mean duration 22.4 years) and poor outcome (mean duration 24.2 years) (p = 0.49). The proportion of patients with good outcome was slightly higher in the shorter duration groups. (Duration less than 10 years 75%, 10–19 years 71%, 20–29 years 65%, 30–39 years 62%, and 40–49 years 60% good outcome, p = 0.95).ConclusionWe found no significant associations between outcome and duration of epilepsy.     

The impact of stereotactic laser ablation at a typical epilepsy center

PurposeStereotactic laser ablation (SLA) is a novel form of epilepsy surgery for patients with drug-resistant focal epilepsy. We evaluated one hundred consecutive surgeries performed for patients with epilepsy to address the impact of SLA on our therapeutic approach, as well as patient outcomes.MethodsA retrospective, single center analysis of the last one hundred neurosurgeries for epilepsy was performed from 2013 to 2015. Demographics, surgical procedures, and postoperative measures were assessed up to 5 years to compare the effect of SLA on outcome. Confidence intervals (CI) and comparative tests of proportions compared outcomes for SLA and resective surgery. Procedural categorical comparison used Chi-square and Kaplan–Meier curves. Student t-test was utilized for single variables such as age at procedure and seizure onset.ResultsOne hundred surgeries for epilepsy yielded thirty-three SLAs and twenty-one resections with a mean of 21.7-month and 21.3-month follow-up, respectively. The temporal lobe was the most common target for SLA (92.6%) and resection (75%). A discrete lesion was present on brain magnetic resonance imaging (MRI) in 27/32 (84.4%) of SLA patients compared with 7/20 (35%) of resection patients with a normal MRI. Overall, 55–60% of patients became seizure-free (SF). Four of five patients with initial failure to SLA became SF with subsequent resection surgery. Complications were more frequent with resection although SF outcomes did not differ (Chi square; p = 0.79). Stereotactic laser ablation patients were older than those with resections (47.0 years vs. 35.4 years, p = 0.001). The mean length of hospitalization prior to discharge was shorter for SLA (1.18 days) compared with open resection (3.43 days; SD: 3.16 days) (p = 0.0002).ConclusionWe now use SLA as a first line therapy at our center in patients with lesional temporal lobe epilepsy (TLE) before resection. Seizure-free outcome with SLA and resection was similar but with a shorter length of stay. Long-term follow-up is recommended to determine sustained SF status from SLA.     

Delayed complications after Gamma Knife surgery for intractable epilepsy

Despite the controversy concerning the clinical usefulness of Gamma Knife surgery (GKS; Elekta AB, Stockholm, Sweden) for intractable epilepsy, this treatment modality has attracted attention due to its low invasiveness. We report the long-term outcomes of four patients, focusing particularly on the efficacy and complications of GKS. We reviewed the data of four patients with medically intractable epilepsy who underwent GKS between 1998 and 2000 at our hospital. The marginal dose to the 50% isodose line was 24 Gy in one patient and 20 Gy in the remaining three patients. Two of the four patients were treated in the right temporal lobe, one was treated in the left parietal lobe, and one was treated in the right frontal lobe. The mean follow-up was 12.5 years (range 12–14 years). One patient was seizure free (Engel class IA) 24 months after GKS, and two patients failed to show any seizure reduction (Engel class IVA). However, a clear aggravation was evident in one patient (Engel class IVC). All four patients underwent resective surgery due to radiation necrosis (RN) 7, 10, 10 and 12 years after GKS. Three patients were seizure free (Engel class IA), and one was considered to have Engel class IB status following the resective surgery. GKS treatment resulted in insufficient seizure control and carried a significant risk of RN after several years. Drawbacks such as a delay in seizure control and the risk of RN should be considered when the clinical application of this treatment is evaluated.     

Surgical treatment of neuronal-glial tumors of mesial-basal part of temporal lobe: Long term outcome and control of epilepsy in pediatric patients

Background

Neuronal-glial tumors (ganglioglioma and dysembryoplastic neuroepithelial tumor) are a frequent cause of focal, drug-resistant and epilepsy in children and young adults, that is amenable for surgical treatment.

Long-term outcome and predictors of resective surgery prognosis in patients with refractory extratemporal epilepsy

PurposeWe analyzed the long-term postoperative outcome and possible predictive factors of the outcome in surgically treated patients with refractory extratemporal epilepsy.MethodsWe retrospectively analyzed 73 patients who had undergone resective surgery at the Epilepsy Center Brno between 1995 and 2010 and who had reached at least 1 year outcome after the surgery. The average age at surgery was 28.3 ± 11.4 years. Magnetic resonance imaging (MRI) did not reveal any lesion in 24 patients (32.9%). Surgical outcome was assessed annually using Engel's modified classification until 5 years after surgery and at the latest follow-up visit.ResultsFollowing the surgery, Engel Class I outcome was found in 52.1% of patients after 1 year, in 55.0% after 5 years, and in 50.7% at the last follow-up visit (average 6.15 ± 3.84 years). Of the patients who reached the 5-year follow-up visit (average of the last follow-up 9.23 years), 37.5% were classified as Engel IA at each follow-up visit. Tumorous etiology and lesions seen in preoperative MRI were associated with significantly better outcome (p = 0.035; p < 0.01). Postoperatively, 9.6% patients had permanent neurological deficits.ConclusionSurgical treatment of refractory extratemporal epilepsy is an effective procedure. The presence of a visible MRI-detected lesion and tumorous etiology is associated with significantly better outcome than the absence of MRI-detected lesion or other etiology.     

Does F-18 FDG-PET substantially alter the surgical decision-making in drug-resistant partial epilepsy?

ObjectiveThere is a dearth of information on the critical utility of positron emission tomography (PET) in choosing candidates for epilepsy surgery especially in resource-poor countries where it is not freely available. This study aimed to critically analyze the utility of FDG-PET in the presurgical evaluation and surgical selection of patients with DRE based on the results obtained through its use in our comprehensive epilepsy program.MethodsFrom 2008 to 2012, 117 patients with drug-resistant epilepsy underwent F-18 fluoro-deoxy-glucose (FDG) PET in our center. We utilized their data to audit the utility of PET in choosing/deferring patients for surgery.ResultsOf the 117 patients (age: 5–42 years) who underwent F-18 FDG-PET, 64 had normal MRI, and 53 had lesions. Electroclinical data favored temporal ictal onset in 48 (41%), extratemporal in 60 (51.3%), and uncertain lobar localization in 9 (7.7%). The topography of PET hypometabolism was localizing in 53 (45.3%), lateralizing in 12 (10.3%), and 52 (44.4%) had either normal or discordant results. In the nonlesional group, focal hypometabolism was concordant to the area of ictal onset in 27 (41.5%) versus 38 (58.5%) in the lesional group (p = 0.002). Greater concordance was noted in temporal lobe epilepsy (TLE) (78.0%) as compared to extratemporal epilepsy (ETPE) (28.6%) (p < 0.001). Positron emission tomography was more concordant in patients with mesial temporal sclerosis than in those with other lesions (82.8% versus 50%) (p = 0.033). Positron emission tomography helped in surgical decision-making in 68.8% of TLE and 23.3% of ETPE cases. Overall, 37 patients (31.6%) were directly selected for resective surgery based on PET results.ConclusionsPositron emission tomography, when utilized judiciously, remained an ancillary tool in the surgical selection of one-third of patients with drug-resistant partial epilepsy, although its utility as an independent tool is not very promising.     

Drug-resistant focal epilepsy in women of childbearing age: Reproduction and the effect of epilepsy surgery

ObjectiveWomen with epilepsy (WWE) have lower birth rates than expected. The reasons for this are multifactorial and involve a complex interaction between reproductive endocrine and psychosocial factors. The effect of epilepsy surgery on reproduction in women with drug-resistant focal epilepsy has not previously been studied.MethodsAdult women of childbearing age (18–45 years old) with drug-resistant focal epilepsy who had undergone a focal cortical resection between 1997 and 2008 at the Mayo Clinic in Rochester, MN were included in the study. Patients who had a history of hysterectomy or tubal ligation or who were menopausal at the time of surgery were excluded. Data on prior pregnancies and births, epilepsy history, surgical treatment, hormonal dysfunction, and socioeconomic status were obtained using a retrospective chart review. Associations between various clinical and demographic variables with changes in pregnancies and births from pre- to postsurgery were assessed using Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. All tests were 2-sided, and p-values less than 0.05 were considered statistically significant. All analyses were performed using SAS software version 9.2 (SAS INC, Cary NC).ResultsOne hundred and thirteen women (average age: 30.5 years) were included in the study. Average length of follow-up was 5.7 years (SD-3.90). Sixty-four patients (57.5%) were nulliparous at the time of surgery. Sixty-one patients (54%) had never been married. Average number of pregnancies per patient prior to surgery was 0.93, and average number of births prior to surgery was 0.73. After surgery, a total of 17 women had a total of 35 pregnancies and 25 births. The average number of pregnancies and births after surgery was 1.27 and 0.96, respectively. Infertility was reported in one patient postoperatively. Patients who were younger at the time of surgery experienced a greater change in the number of pregnancies and births after surgery (p = 0.0036 and 0.0060, respectively). Patients who received fewer antiepileptic drug medication trials by the time of surgery also had a greater change in the number of births after surgery (p = 0.0362). Seizure onset localization and lateralization, presurgical seizure frequency, age at seizure onset, duration of epilepsy, and postoperative seizure outcome were not statistically significant factors.ConclusionThe present retrospective observational study provides additional evidence for the importance of early surgical treatment in women with drug-resistant focal epilepsy. Patients who had received fewer medications prior to surgery were more likely to experience an increase in births following surgery. The significance of these findings requires further investigation but may support a role for earlier surgical intervention in the management of drug-resistant focal epilepsy.     

To what extent does depression influence quality of life of people with pharmacoresistant epilepsy in Argentina?

IntroductionDepression is the most frequent psychiatric co-morbidity in patients with epilepsy. Lifetime prevalence of depression is reported more frequently in temporal lobe epilepsy and is estimated at 35%. This co-morbidity appears to be related with various mechanisms. The aim of this study was to determine the quality of life (QoL) of patients with pharmacoresistant epilepsy with and without co-morbid depression in an Argentinean population.MethodsPatients admitted to the video-EEG monitoring unit during the period 2010–2013 went through a standardized psychiatric assessment using SCID-I (Structured Clinical Interview for Axis I diagnoses of DSM-IV), BDI II (Beck Depression Inventory) GAF (Global assessment of functioning), and Q LES Q-SF (for quality of life). Patients were divided in two groups: with and without depression (according to DSM-IV). Sociodemographic data, BDI II scores, GAF, and quality of life (QoL) were compared between the two groups. Comparisons were made using Student's t-test and Mann–Whitney U test. Frequency distributions were compared by Chi-square test. Spearman correlation coefficients were determined.ResultsSeventy-seven patients with pharmacoresistant epilepsy were eligible for this study, 41 patients were included in the group with depression (mean BDI II 15.93), and 36 in the group without depression (mean BDI II 3.36) (p = 0.001). The overall QoL was significantly lower in the group with depression compared to the group without depression (p < 0.01). The most affected areas were: physical health (p = 0.013), mood (p = 0.006), course activities (referring to school as well as to hobbies or classes outside of school) (p = 0.003), leisure time activities (p = 0.011), social activities (p = 0.047), general activities (p = 0.042), and medication (p = 0.022). Severity of depression according to BDI II had a negative correlation with overall QoL (r - 0.339, p < 0.01). No correlations were found between seizure frequency, QoL and BDI II.ConclusionPatients with pharmacoresistant epilepsy and co-morbid depression reported worst QoL. Depression disrupts daily functioning (leisure, social functioning) and is a negative influence for subjective perception of health and medication. Interdisciplinary treatment should be considered (neurology–psychiatry–psychotherapy).