顽固性癫痫行前颞叶切除术的并发症

目的报告顽固性颞叶癫痫行前颞叶切除的并发症,探讨术后并发症的发生率、原因和预防措施。方法顽固性颞叶癫痫患者行前颞叶切除,术后出现急性脑梗死伴颅内感染、硬膜外血肿、轻偏瘫等情况,采取抗炎、抗脑水肿、抗凝治疗及清除血肿等治疗。结果首例病人卡马西平治疗随访1年,癫痫发作消失;第2例随访7年,癫痫发作消失;第3例癫痫消失,但残留轻偏瘫,后渐恢复,遗留左手指屈伸力差。结论血肿和感染是术后最频发的并发症,偏瘫(操作性偏瘫)是最严重的神经并发症,手术时损伤脉络膜前动脉是最可能导致偏瘫的原因。     

Social outcomes after temporal or extratemporal epilepsy surgery: a systematic review

Purpose: The objective of this study was to systematically review the literature to assess social outcomes after epilepsy surgery. Methods: A systematic literature search was conducted as part of a larger project on the development of an appropriateness and necessity rating tool to identify patients with focal epilepsy that may benefit from an epilepsy surgery evaluation. Studies were included if they reported postsurgical data on social outcomes (employment, driving, social relationships, marriage, education, financial status, behavior, and social interactions) and had a follow‐up period of at least 24 months. Our search strategy yielded 5,061 studies. Sixty‐five of these studies addressed social outcomes, but only 19 met all eligibility criteria. Key Findings: In adults, a significant improvement in full‐time employment postsurgery was documented. The ability to drive was significantly increased after surgery and was dependent on seizure freedom. Patients generally perceived improved relationships, independence, and overall lifestyle postsurgery. Marital status generally remained unchanged when compared to controls, education improved modestly, and income/financial status changes depended on how it was assessed (e.g., income level vs. receipt of disability pension). In children, a study examining behavior showed improved social interactions in those who underwent surgery compared to controls. The results for other social outcome categories were more variable. Significance: Overall, the majority of studies reported improvement in social outcomes after surgery. However, prospective controlled observational studies using objective social outcome measures are necessary prior to making specific conclusions about the influence of surgery on social outcomes other than employment or driving status in all age groups, but particularly in children and the elderly.     

Long-term psychosocial outcomes of anterior temporal lobectomy

PURPOSE: To examine the long-term psychosocial outcomes of a consecutive series of patients who underwent anterior temporal lobectomy (ATL) compared with medically managed patients. This study focused primarily on actual long-term changes (mean, 5 years) in life performance. There are relatively few long-term controlled studies of actual lifetime performance changes. METHODS: The sample consisted of 61 adults who underwent ATL and 23 individuals who were evaluated for surgery but did not proceed to surgery and continued to receive medical management. Participants were interviewed 2-9 years after surgery. A structured clinical interview and review of medical records was conducted to obtain information regarding seizure frequency and psychosocial status, focusing on employment, education, driving status, financial assistance, and independent living. In addition, two questions regarding quality of life were included. Seizure frequency was evaluated for the year before the interview. RESULTS: Significant differences in psychosocial outcome were found between the surgery group and medical management group. Favorable psychosocial outcomes were more common among those who had surgery (46 vs. 4%). Results indicated that 68% of the surgery group exhibited improved psychosocial status compared with 5% of the medical management group. Individuals who had surgery were more likely to be driving, working full-time, living independently, and being financially independent. Remaining seizure free was not a prerequisite for improvements in psychosocial outcomes. CONCLUSIONS: Compared with medical management, surgery has a significant positive impact on psychosocial outcomes in terms of employment, independent living, driving, and financial independence. Additionally, a person does not necessarily have to be seizure free to achieve positive changes in psychosocial outcomes.     

Short-term neurocognitive outcomes following anterior temporal lobectomy

Changes in cognitive function are a well established risk of anterior temporal lobectomy (ATL). Deficits in verbal memory are a common postoperative finding, though a small proportion of patients may improve. Postoperative evaluation typically occurs after six to 12 months. Patients may benefit from earlier evaluation to identify potential needs; however, the results of a formal neuropsychological assessment at an early postoperative stage are not described in the literature. We compared pre- and postoperative cognitive function for 28 right ATL and 23 left ATL patients using repeated measures ANOVA. Changes in cognitive function were compared to ILAE seizure outcome. The mean time to postoperative neuropsychological testing was 11.1 weeks (SD = 6.7 weeks). There was a side × surgery interaction for the verbal tasks: immediate memory recall (F(1,33) = 20.68, p < 0.001), short delay recall (F(1,29) = 4.99, p = 0.03), long delay recall (F(1,33) = 10.36, p = 0.003), recognition (F(1,33) = 5.69, p = 0.02), and naming (F(1,37) = 15.86, p < 0.001). This indicated that the left ATL group had a significant decrement in verbal memory following surgery, while the right ATL group experienced a small but significant improvement. For the right ATL group, there was a positive correlation between ILAE outcome and improvement in immediate recall (r = − 0.62, p = 0.02) and long delay recall (r = − 0.57, p = 0.03). There was no similar finding for the left ATL group. This study demonstrates that short-interval follow-up is effective in elucidating postoperative cognitive changes. Right ATL was associated with improvement in verbal memory, while left ATL resulted in a decrement in performance. Improvement in the right ATL group was related to improved seizure outcome. Short-interval follow-up may lend itself to the identification of patients who could benefit from early intervention.     

Memory outcome 2 years after anterior temporal lobectomy in patients with drug-resistant epilepsy

PURPOSE: Memory decline is often observed after anterior temporal lobectomy (ATL), particularly in patients with dominant hemisphere resections. However, the follow-up length has been 1 year or less in most studies. Our aims were to examine postoperative memory changes over a longer period and to identify baseline demographic and clinical predictors of memory outcome. METHODS: We administered material-specific memory tests at baseline, and 1 and 2 years after surgery to 82 consecutive right-handed patients (52% males) who underwent ATL for drug-resistant temporal lobe epilepsy (TLE) (35 left, 47 right) after a non-invasive presurgical protocol. Repeated measures multivariate analysis of variance (RM-MANOVA) was used to examine the relationship between changes in memory tests scores over time and side of TLE and pathology. Also, standardized residual change scores were calculated for each memory test and entered in multiple linear regression models aimed at identifying baseline predictors of better memory outcome. RESULTS: RM-MANOVA revealed a significant change in memory test scores over time, with an interaction between time and side of surgery, as 2 years after surgery patients with RTLE were improved while patients with LTLE were not worse as compared with baseline. Pathology was not associated with changes in memory scores. In multiple regression analysis, significant associations were found between right TLE and greater improvement in verbal memory, younger age and greater improvement in visuospatial memory, and male gender and greater improvement in both verbal and visuospatial memory. CONCLUSIONS: Our results suggest that the long-term memory outcome of TLE patients undergoing ATL without invasive presurgical assessment may be good in most cases not only for right-sided but also for left-sided resections.     

Non-invasive examinations successfully select patients with medial temporal lobe epilepsy for anterior temporal lobectomy]

We retrospectively analyzed 8 patients with intractable medial temporal lobe epilepsy (MTLE) who underwent the anterior temporal lobectomy with hippocampectomy (ATL) without invasive examinations such as chronic subdural electrode recording. Five patients had a history of febrile convulsion. While all 8 patients had oral automatism, automatism of ipsilateral limbs with dystonic posture of contralateral limbs was demonstrated in 2 patients. Bilateral temporal paroxysmal activities on interictal EEG was observed in 4 patients and all patients had clear ictal onset zone on unilateral anterior temporal region. MRI demonstrated unilateral hippocampal sclerosis in 5 cases. Interictal FDG-PET depicted hypometabolism of the unilateral temporal lobe in all cases, however, ECD-SPECT failed to reveal the hypoperfusion of the unilateral temporal lobe in a case. Postoperatively, 7 cases became seizure free, and one had rare seizure. Non-invasive examinations, especially ictal EEG and concordant FDG-PET findings, in patients with oral automatism in seizure semiology, successfully select patients with MTLE for ATL.     

Psychiatric aspects of temporal lobe epilepsy before and after anterior temporal lobectomy

OBJECTIVES: Psychopathology has been reported to be prevalent both before and after surgical treatment for medically intractable temporal lobe epilepsy. Individual patients were evaluated prospectively to assess the effect of anterior temporal lobectomy (ATL) on prevalence and severity of psychiatric disease. METHODS: Psychiatric status was assessed in a consecutive series of epilepsy patients before and 6 months after ATL using a structured psychiatric interview, psychiatric rating scales, and self report mood measures. RESULTS: A DSM-III-R axis I diagnosis was present in 65% of patients before and after surgery. The most common diagnoses were depression, anxiety, and organic mood/personality disorders. There was a trend for major psychiatric diagnoses to be more common in patients with right compared to left temporal lobe seizure focus, both before and after surgery. The apparent stability in the overall rate of psychiatric dysfunction concealed onset of new psychiatric problems in 31% of patients in the months shortly after surgery, and resolution of psychiatric diagnoses in 15% of patients. In the group as a whole, the severity of psychiatric symptoms was lower at 6 months postsurgery than before temporal lobectomy. CONCLUSIONS: The overall prevalence of psychiatric dysfunction was comparably high before and after ATL, but individual changes in psychiatric status and changes in severity of symptoms occurred in many patients in the 6 months after surgery.     

Manganese and epilepsy: a systematic review of the literature

Manganese is an essential trace element for the development and function of the central nervous system. Alterations in manganese concentrations, whether excessive or deficient, can be accompanied by convulsions. This article represents a systematic review of available quantitative evidence that might clarify this issue. We searched The Cochrane Library, Medline and LILACS databases from January 1966 through June 2006 and reviewed all resulting English and Spanish language publications, as well as those possibly relevant in other languages based on their abstracts. The final selection included for this review comprises all investigations in humans and animals that compared manganese levels in any tissue of a group with spontaneous or induced convulsions (with or without antiepileptic treatment) and a convulsion-free control group. The literature search identified thirteen publications since then relevant to the issue, four of which failed to meet our criteria for inclusion. Of the remaining nine, six were in humans and three in rodents. At present, there is no satisfactory explanation for the relationship between low manganese levels and the presence of convulsions. There is a documented correlation between low blood manganese levels and the presence of convulsions in both humans and animals. The lack of evidence indicating whether this is a cause or an effect of the convulsions clearly justifies more detailed follow-up investigations in humans.     

Psychiatric outcomes of epilepsy surgery: a systematic review

Purpose: The objective of this systematic review was to identify: (1) prevalence and severity of psychiatric conditions before and after resective epilepsy surgery, (2) incidence of postsurgical psychiatric conditions, and (3) predictors of psychiatric status after surgery. Methods: A literature search was conducted using PubMed, EmBase, and the Cochrane database as part of a larger project on the development of an appropriateness and necessity rating tool to identify patients of all ages with potentially resectable focal epilepsy. The search yielded 5,061 articles related to epilepsy surgery and of the 763 articles meeting the inclusion criteria and reviewed in full text, 68 reported psychiatric outcomes. Thirteen articles met the final eligibility criteria. Key Findings: The studies demonstrated either improvements in psychiatric outcome postsurgery or no changes in psychiatric outcome. Only one study demonstrated deterioration in psychiatric status after surgery, with higher anxiety in the context of continued seizures post‐surgery. One study reported a significantly increased rate of psychosis after surgery. The two main predictors of psychiatric outcome were seizure freedom and presurgical psychiatric history. De novo psychiatric conditions occurred postsurgery at a rate of 1.1–18.2%, with milder psychiatric issues (e.g., adjustment disorder) being more common than more severe psychiatric issues (e.g., psychosis). Significance: Overall, studies demonstrated either improvement in psychiatric outcomes postsurgery or no change. However, there is a need for more prospective, well‐controlled studies to better delineate the prevalence and severity of psychiatric conditions occurring in the context of epilepsy surgery, and to identify specific predictors of psychiatric outcomes after epilepsy surgery.     

Anterior temporal lobectomy combined with anterior corpus callosotomy in patients with temporal lobe epilepsy and mental retardation

AimsTo investigate the surgical outcomes of anterior corpus callosotomy (aCCT) combined with anterior temporal lobectomy (ATL) in patients with intractable temporal lobe epilepsy (TLE) and mental retardation (MR).MethodsSixty patients with TLE and MR were carefully selected and randomly divided into two equal groups: ATL and aCCT, in which they were treated with ATL or ATL combined with aCCT, respectively. Surgical outcomes, including seizure control, IQ and quality of life (QOL) changes, as well as complications were recorded and analyzed 2 years after operation.ResultsSeizure-free status had been achieved in 66.7% of all patients. The aCCT group had higher percentage in Engle Classes I–II than the ATL group (96.7% vs. 80.0%, P < 0.05). 56.7% of patients in ATL group and 63.3% in aCCT group had improved full scale IQ (FIQ) after surgery, while the decline of FIQ in aCCT group was less than that of ATL group (3.3% vs. 30.0%). Compared with pre-operative score, the mean post-operative score of performance IQ in aCCT group had improved. Significant difference in QOL change had been found between two groups (P < 0.001). 73.7% of patients in aCCT group had their QOL improved with no long-term complications.ConclusionsATL combined with aCCT can improve QOL and performance IQ in patients with TLE and MR.     

Preoperative IQ predicts seizure outcomes after anterior temporal lobectomy

PurposeIQ tests are frequently used in the preoperative neuropsychological assessment of candidates for anterior temporal lobectomy (ATL). We reviewed IQ test results and surgery outcomes to evaluate the roles of IQ tests in the preoperative work-up.MethodsA total of 205 adult patients who had undergone ATL and whose seizure outcomes were followed for 2 years after surgery were included. The short form WAIS-R was used to estimate intelligence. Multiple linear regression and logistic regression analyses were used to examine the variables for IQ and seizure outcomes.ResultsEducation, duration of epilepsy and gender were factors that accounted for 24.6% of the variance in the full-scale IQ (FSIQ) scores. The verbal IQ and performance IQ discrepancies at various magnitudes could not lateralize the seizure foci. Freedom of seizure was noted in 128 (62.4%) of the patients. Seizure outcomes, however, correlated with the preoperative FSIQ. After adjustment for variables that affect seizure outcomes, the FSIQ was an independent predictor of postoperative seizure outcomes (OR 1.04, 95% CI 1.01–1.06, p = 0.003). Of patients who had FSIQ lower than 70, 50% became free from seizures by 2 years after surgery.ConclusionsIn our study, IQ tests were unable to lateralize seizure foci but may serve as an independent predictor of postoperative seizure outcomes. Since a longer duration of epilepsy had deleterious effects on intelligence, earlier surgical intervention might better preserve neuropsychological function and, consequently, allow better seizure control after ATL. Nonetheless, patients with lower IQ scores could still benefit from ATL.     

颞叶癫(癎)患者前颞叶切除对认知功能影响的短期观察

目的评价难治性颞叶癫患者一侧标准前颞叶切除术后短期内对认知功能的影响。方法23例左前颞叶切除和42例右前颞叶切除患者在术前及术后3个月分别行韦氏智力及韦氏记忆量表测定,观察相应指标的变化。结果65例标准前颞叶切除患者术前言语智商(VIQ)、操作智商(PIQ)及全量表智商(FIQ)各值分别为80.5±15.6、89.9±16.2和83.3±15.2;术后3个月为74.3±16.1、81.8±15.9和76.1±15.2,术后各值虽较术前下降,但经配对t检验,差异无统计学意义(P>0.05)。记忆商数(MQ)值术前为70.7±20.5,术后3个月为57.5±22.3,较术前下降明显(P<0.05)。左前颞叶切除患者术前VIQ、PIQ、FIQ及MQ各值分别为78.6±15.6、87.5±17.8、81.1±16.2和69.1±22.4,术后3个月分别为66.5±11.9、77.9±18.6、69.7±14.2和49.9±18.8,术后各项指标下降明显,与术前比较差异均有统计学意义(P<0.05);右前颞叶切除患者术前VIQ、PIQ、FIQ及MQ各值分别为81.9±15.7、91.9±14.9、84.9±14.4和71.8±19.3,术后3个月分别为80.2±16.6、84.7±13.1、81.0±14.3和63.3±23.3,术后所有指标下降均无统计学意义(P>0.05)。结论一侧标准右前颞叶切除患者短期内对认知功能的影响较左前颞叶切除者小。     

难治性颞叶癫痫术后生活质量的评估

目的调查药物难治性颞叶癫痫术后患者生活质量的改善情况,评估手术对该类患者生活质量的影响。方法将自理能力、学习能力、工作能力、经济收入四个指标作为生活质量的评定标准,对比168例药物难治性颞叶癫痫患者手术前后生活质量的变化,并进行统计学分析。结果 168例药物难治性颞叶癫痫患者经过严格的术前评估均行前颞叶切除,随访1-3年,术后生活质量较术前明显改善,有统计学意义。结论药物难治性颞叶癫痫患者术后生活质量明显改善,手术显示出良好的性价比,有手术指证的患者应积极手术治疗。     

不同术式选择对颞叶癫痫患者术后记忆功能影响的初步探讨

目的探讨不同术式选择对颞叶癫痫患者术后记忆功能的影响。方法 2009~2013年共248例海马硬化性颞叶癫痫患者在我院接受手术治疗,其中83例行标准前颞叶切除术(anterior temporal lobectomy,ATL),165例行选择性海马杏仁核切除术(selective amygdalohippocampectomy,SAH)。患者在术前、术后3个月及术后两年分别接受临床记忆功能评估。结果 ATL组和SAH组优势半球侧手术的患者临床记忆商数(memory quotient,MQ)在术后3个月(74.5±16.2,75.6±19.5)均有明显下降(P0.05),术后两年(75.1±14.1,76.1±17.6)略有恢复但仍然显著低于术前(82.9±15.8,83.2±21.2)(P0.05),其中SAH组术后3个月及术后两年相较术前MQ的减低程度都小于ATL组(7.6 vs.8.4;7.1 vs.7.8);ATL组和SAH组非优势半球侧手术的患者术后3个月的MQ(87.2±15.1,88.1±16.9)均高于术前(85.5±13.5,85.3±19.7),但无统计学意义,至术后两年时,两组患者的MQ(92.8±12.7,93.7±17.1)对比术前都有了显著的改善(P0.05),其中SAH组患者的改善幅度较ATL组略大(8.4 vs.7.3)。结论相比于ATL,SAH可能更有利于保护海马硬化性颞叶癫痫患者的术后记忆功能。     

前颞叶切除范围与视野缺损关系的弥散张量成像分析

目的 观察颞叶癫痫患者前颞叶切除术后视野缺损的发生率以及手术切除范围与视野缺损的关系.方法 25例前颞叶切除术的患者于术前及随访时行视野、磁共振(含DTI弥散张量序列)检查,根据视野缺损严重程度的不同将患者分为A、B、C三级.手术后视放射的各向异性分数(FA值)的下降(△FA)代表Meyer袢受损情况.比较不同视野缺损组之间前颞叶切除范围的差异;并对切除范围和△FA进行线性相关分析.结果 前颞叶切除术后22例患者出现象限盲.前颞叶平均切除长度:A组31.1 mm,B组42.5 mm,C组50.4 mm,A＜B＜C组(P＜0.05).手术侧的△FA与切除范围旱线性相关.结论 前颞叶切除术破坏视放射导致视野缺损较常见.有必要术前应用DTI获得患者视放射的信息,进行术前风险评估.

Abstract：

Objective Anterior temporal lobectomy(ATL) for temporal lobe epilepsy (TLE) is the most commonly performed epilepsy surgery procedure.A visual field defect(VFD) due to the injury to the optic radiation may occur after ATL.DTI technique can visualize the optic radiation (OR) noninvasively.This study aimed at evaluating the incidence of VFD after ATL and investigating whether the resection size of lateral ATL correlated with the extent of VFD.We tried to explain the impact of ATL on the OR and to investigate the anterior extending of Meyer loop with DTI technology.Method 25 patients( 14male, 11 female) underwent ATL for treatment of epilepsy.The patients were aged from 13 to 39 years old ( mean age:22.4 yrs).All cases were classified into three groups on the basis of the severity of VFD( A ～ C,with group C the most severe).All patients had preoperative and follow up clinical and MRI( including DTI series) examinations.The clinical and MRI(DTI) outcomes of these patients were retrospectively analyzed.Results At mean follow up period of 31.3 weeks ( range, 17 - 42 weeks), we found 22 patients become quadrantanopia due to the injury to OR after ATL.A significant reduction of fractional anisotropy was demonstrated in the OR on the side of the temporal lobectomy.The severity of VFD decreased according to the reducing of the mean resection size(group A, 31.1 mm;group B 42.5 mm;C, 50.4 mm), P ＜0.05.There was linearship between the resection size and the FA decrease.Conclusions VFD due to the injury to the OR was not uncommon after ATL There was an association between the resection size and severity of VFD.Optic radiation showed a decreased FA value in cases after ATL.There is considerable intersubjective variance about the OR, so it is necessary to get the patient's DTI information about the OR before the operation ,which could help to assess the preoperative risks.     

Functional connectivity of hippocampus in temporal lobe epilepsy depends on hippocampal dominance: a systematic review of the literature

Journal of Neurology - Lateralized alterations in hippocampal function in the resting-state have been demonstrated for patients with temporal lobe epilepsy (TLE). However, resting-state fMRI of the...     

Nonverbal memory functioning following right anterior temporal lobectomy: a meta-analytic review.

PURPOSE: Studies investigating nonverbal memory functioning following right anterior temporal lobectomy (RATL) in patients with intractable temporal lobe epilepsy have resulted in conflicting findings, as nonverbal memory deficits have been reported for some, but not all patients. To examine the association between nonverbal memory deficits and RATL, the present study employed meta-analytic principles in a quantitative review of the literature. METHODS: Thirteen studies, reporting pre- and postoperative nonverbal memory performance for a total of 324 RATL patients, were identified. Effect sizes were calculated to measure the extent of nonverbal memory deficit in patients following RATL. Additionally, effect sizes for primary studies comprising a common dependent variable were combined using standard meta-analytic procedures. RESULTS: Of the 22 dependent variables utilized to assess nonverbal memory, 14 indicated postoperative declines in functioning while 8 demonstrated postoperative improvements in performance. All resultant effect sizes were relatively small. Mean effect sizes calculated for dependent variables used in multiple studies identified the Warrington Recognition Memory Test for Faces as the only nonverbal memory measure which produced consistent results. CONCLUSIONS: Overall, the collective findings demonstrate the inability of the current research to provide any consistent evidence as to the nature of nonverbal memory outcome following RATL. Problems with nonverbal memory measures are discussed and suggestions for future research are proposed.     

WMS-III performance in epilepsy patients following temporal lobectomy.

We examined performances on the Wechsler Memory Scale-3rd Edition (WMS-III) among patients who underwent temporal lobectomy for the control of medically intractable epilepsy. There were 51 right (RTL) and 56 left (LTL) temporal lobectomy patients. All patients were left hemisphere speech-dominant. The LTL and RTL patients were comparable in terms of general demographic, epilepsy, and intellectual/attention factors. Multivariate analyses revealed a significant crossover interaction (p <.001), with the RTL group scoring significantly lower on the visual than auditory indexes while the LTL group scored significantly lower on the auditory than visual memory indexes. Within-group pairwise analyses revealed statistically significant auditory versus visual index score comparisons (all p <.001) for both surgical groups. Discriminant analysis (p <.001) identified Verbal Paired Associates I, Faces I, and Family Pictures II to significantly discriminate RTL and LTL patients, with an overall correct classification rate of 81.3%. Our findings suggest that the WMS-III is sensitive to modality-specific memory performance associated with unilateral temporal lobectomy.