癫痫无发作患者撤药后的长期结局及复发的危险因素分析

目的 探讨癫痫无发作患者撤药后的长期结局及影响复发的危险因素。方法 本研究包含141例至少3年无发作的癫痫患者,自撤药开始随访至少3年或直到癫痫复发; 根据是否复发分为无发作组和复发组; 对连续变量和分类变量分别采用t检验和卡方检验。用多元回归分析复发危险因素。Kaplan-Meier生存曲线用来计算累积复发率。结果 141例患者中63例(44.7%)复发,78例(55.3%)在随访结束时仍无发作。平均复发时间是撤药后14个月,大多数复发在24个月内(81.0%); 撤药后的累积复发率在第6、12、24、36、48、60个月分别为19.1%、29.8%、36.2%、42.6%、43.4%、43.4%。单因素分析显示早期3个月内药物未控制发作组复发率高于早期3个月内药物控制发作组; 围产期损伤组复发率高于无围产期损伤组、需多药控制者组复发率高于单药控制组。进一步多因素回归分析发现有围产期损伤[风险比(HR)=5.000,95%置信区间(CI)=1.428～17.544]和需多药控制(HR=3.509,95% CI=1.545～8.000)是复发的独立危险因素。结论 癫痫复发主要发生在开始撤药后的前24个月,撤药后3年的无发作保留率为57.4%。撤药后复发的独立危险因素是有围产期损伤史和需多药控制。     

Discontinuation of antiepileptic drugs after successful epilepsy surgery

OBJECTIVE: To evaluate the frequency and risk factors for seizure recurrence subsequent to antiepileptic drug (AED) withdrawal in patients who underwent surgical treatment for intractable partial epilepsy and were rendered seizure-free. METHODS: The outcome of discontinuation of AED medication was studied retrospectively in 210 consecutive patients who were rendered seizure-free after epilepsy surgery performed between 1989 and 1993. RESULTS: Medical therapy was reduced in 96 patients and discontinued in 84 patients. The seizure recurrence rate after complete AED withdrawal was 14% and 36% at 2 and 5 years. In contrast, only 3% and 7% of the 30 patients who did not alter AED treatment after surgery had recurrent seizures in the same time intervals. After AED discontinuation, seizures tended to recur more often in patients with normal preoperative MRI studies compared with those with focal pathology. However, this difference did not reach significance. Intraoperative electrocorticography, extent of surgical resection, postoperative EEG, and seizure-free duration after surgery were not predictive of seizure outcome after AED withdrawal. CONCLUSIONS: AED withdrawal was associated with seizure recurrence in a significant portion of patients rendered seizure-free by epilepsy surgery. Patients with a normal preoperative MRI study showed a tendency for higher seizure recurrence, whereas the duration of seizure-free postoperative AED treatment interval did not significantly influence the seizure recurrence rate. These results will prove useful in counseling patients about discontinuing AED treatment after successful epilepsy surgery.     

Antiepileptic drug withdrawal after successful surgery for intractable temporal lobe epilepsy

PURPOSE: To investigate the prognosis related to antiepileptic drug (AED) discontinuation after successful surgery for intractable temporal lobe epilepsy. METHODS: The clinical courses after temporal lobectomies (TLs) were retrospectively analyzed in 88 consecutive patients. All the patients had TLs as the only surgical procedure, and they had been followed up for longer than 3 years. AED discontinuation was attempted if the patient had been seizure free without aura for >or=1 year during the follow-up period. RESULTS: Sixty-six (75%) patients achieved complete seizure freedom for >or=1 year; 28 patients were seizure free immediately after surgery (immediate success); and 38 patients became seizure free after some period of recurrent seizures (delayed success). AED discontinuation was attempted in 60 (91%) of 66 patients with a successful outcome. In 13 (22%) patients, seizure relapse developed during AED reduction (n=60), and in seven (12%) patients after discontinuation of AEDs (n=38). The seizure recurrence rate was not different between the immediate-and delayed-success groups. Among 20 patients with seizure relapse related to AED tapering, nine (45%) of them regained seizure freedom after reinstitution of AED treatment, and AEDs were eventually discontinued in six of them. Seizures that recurred after complete AED discontinuation had a better prognosis than did the seizures that recurred during AED reduction (seizure freedom in 86% vs. 23%). At the final assessment, 54 (61%) patients had been seizure free >or=1 year; 37 without AEDs and 17 with AEDs. The successful discontinuation of AEDs was more frequent for patients with a younger age at the time of surgery and for those patients with shorter disease duration. CONCLUSIONS: Our results suggest that seizure freedom without aura at >or=1 year is a reasonable indication for the attempt at AED discontinuation. The subsequent control of recurrent seizures was excellent, especially if seizures relapsed after the complete discontinuation of AEDs. Younger age at the time of surgery and a shorter disease duration seem to affect successful AED discontinuation for a long-term period.     

Prognosis after withdrawal of antiepileptic drugs in childhood-onset cryptogenic localization-related epilepsies

The purpose of this study was to clarify the risk factors of relapse following discontinuation of AEDs in patients with childhood-onset cryptogenic localization-related epilepsies. The subjects were 82 patients who fulfilled the following criteria: (1) age at first visit of less than 15 years, (2) follow-up period of more than 5 years, (3) suffering from cryptogenic localization-related epilepsies, and (4) the patient underwent AED withdrawal during the follow-up period. As a basic principle, we decided to start withdrawing AEDs when both of the following two conditions were met: (1) the patient had a seizure-free period of 3 years or more, and (2) there were no epileptic discharges on EEGs just prior to the start of withdrawal. Seizures recurred in eight of the 82 patients (9.8%). Univariate analysis revealed that the following factors were correlated with higher rates of seizure relapse: 6 years of age or higher at onset of epilepsy; 15 years of age or higher at the start of AED withdrawal; 5 years or more from the start of AED treatment to seizure control; five or more seizures before seizure control; and two or more AEDs administered before seizure control. Among these risk factors, 6 years of age or higher at onset and 5 years or more from the start of AED treatment to seizure control were determined by multivariate analysis to be independent risk factors for relapse. Thus, we conclude that the physician should be more careful in discontinuing AEDs in these higher-risk patients groups, and more generous in discontinuing AEDs in lower-risk groups.     

Seizure recurrence after planned discontinuation of antiepileptic drugs in seizure-free patients after epilepsy surgery: a review of current clinical experience

PURPOSE: Although epilepsy surgery, especially temporal lobe epilepsy surgery, is well established to control seizures in patients remaining on antiepileptic drug (AED) treatment, less information is available about how many seizure-free surgical patients will relapse after discontinuation of AEDs under medical supervision. METHODS: A literature review yielded six retrospective clinical observations. RESULTS: After planned discontinuation of AEDs in patients rendered seizure free after epilepsy surgery, most often various forms of temporal lobe surgery, the mean percentage recurrence rate in adults in four studies was 33.8%[95% confidence interval (CI), 32.4-35.2%], with maximum follow-up ranging from 1 to 5 years. Seizure recurrence increased during the follow-up of 1 to 3 years and occurred within 3 years of AED discontinuation. In one study of children with temporal lobe epilepsy, the recurrence rate was 20%. More than 90% of adult patients with seizure recurrence regained seizure control with reinstitution of previous AED therapy. Seizure recurrence was unaffected by the duration of postoperative AED treatment; as a consequence, delaying discontinuation beyond 1 to 2 years of complete postoperative seizure control seems to have no added benefit. The occurrence of rare seizures or auras after surgery did not eliminate the possibility of eventual successful AED discontinuation. CONCLUSIONS: AED discontinuation is associated with a seizure recurrence in one in three patients rendered seizure free by epilepsy surgery. These results will be useful in counseling patients about discontinuing AED treatment after successful epilepsy surgery.     

Antiepileptic drug withdrawal in patients with temporal lobe epilepsy undergoing presurgical video-EEG monitoring

PURPOSE: To investigate antiepileptic drug (AED) withdrawal during video-EEG monitoring in adult patients with temporal lobe epilepsy (TLE). METHODS: Between 1995 and 1997, 102 consecutive patients with refractory TLE were admitted to the epilepsy monitoring unit for presurgical evaluation. Patients were monitored with ongoing AEDs being rapidly decreased and discontinued in 4-6 days. The monitoring was continued until sufficient numbers of seizures were recorded. Serum AED levels were checked at admission and after the first complex partial seizure (CPS). RESULTS: In all, 89 patients had 429 CPSs (mean, 4.8 per patient), including 156 (36.4%) secondarily generalized. A mean of 153.8 h (16-451 h) was required for completing the monitoring in each patient. Forty-three (48.3%) patients experienced seizure clusters, and eight (9.0%) had generalized seizures that had never occurred or had been absent for years. However, none evolved to status epilepticus. Carbamazepine was the most commonly used AED in 71.9% of patients, followed by valproate and phenytoin. When the first CPS occurred, mean 77.2 h since the beginning of the monitoring, serum levels of these three AEDs were mostly subtherapeutic rather than minimal. CONCLUSIONS: Acute AED withdrawal effectively provoked seizures in TLE patients undergoing presurgical video-EEG monitoring. However, nearly 50% of patients had seizure clusters or secondarily generalized seizures. Serum AED levels were mostly subtherapeutic when the first CPS occurred.     

Antiepileptic drug treatment before and after selective amygdalohippocampectomy

Retrospectively, we analyzed pre and postoperative (po) AED treatment in relation to long-term annual seizure outcome in the Zurich selective amygdalohippocampectomy (AHE) series. In 376 patients (hippocampal sclerosis ("HS"), n:185; other lesions ("lesional"), n:191) with a follow-up of more than 1 year, in the last available outcome (lao), 60% were seizure- and aura-free (ILAE Class 1). During the year prior to surgery, in the "HS" group a mean of 2.3 +/- 0.8 AEDs were taken. The percentage of patients without AEDs increases to 36.1% in the po years 1-5 (po year 5: "HS" (n:133) 27.8%; "lesional" (n:111) 45.9%). In po years 7-11 this percentage is between 40 and 43% (po year 10: "HS" (n:75) 29.3%; "lesional" (n:65) 55.4%). In the ILAE Class 1a, at po year 5 63/85 (74.1%) patients have discontinued AED intake. At lao 36.2% of patients were off AEDs and additional 18.9% had a "substantial" reduction (i.e. from polytherapy to monotherapy, or a reduction of the existing monotherapy by at least 66% compared to the year before AHE). The relapse rate is similar for patients who were free of disabling seizures (a) for > or =1 year and without AEDs (17.1%), (b) immediately after surgery with or without AEDs (18.4%), and (c) had a "substantial" AED reduction over the entire follow-up period (18.9%). The rate of re-gained full seizure control, however, is significantly better for group (b) compared to (c) (77% versus 53%). 10.9% of patients showed the "running down phenomenon," i.e. had seizures during the first po year, but then became seizure-free for 1 or more years. The percentage of patients free of "disabling" seizures, who did not follow the medical advice to discontinue/reduce AEDs, is about 30% after the 10th po year. In the 15th po year this figure is 4.2 times higher for "HS" versus "lesional" patients. We conclude that the time of discontinuation of AEDs after AHE should be tailored based on the results of the presurgical evaluation, the early po seizure outcome, the histopathological findings, the intraoperative ECoG findings and the po EEG. In an optimal constellation, "substantial" AED reduction with the goal of a monotherapy can be advised 1 year and discontinuation 2 years after surgery.     

Electro-clinical characteristics and postoperative outcome of medically refractory tumoral temporal lobe epilepsy

BACKGROUND: Very few studies have specifically addressed surgical treatment and outcome of patients with tumor-related temporal lobe epilepsy (TLE). AIM: To define the postoperative seizure outcome and the factors that influenced the outcome of patients with tumor-related TLE. MATERIALS AND METHODS: We selected patients whose surgical pathology revealed a temporal lobe neoplasm and who had completed > 1 year of postoperative follow-up. We reviewed the clinical, EEG, radiological and pathological data, and the seizure outcome of these patients and assessed the factors that influenced the outcome. RESULTS: Out of the 409 patients who underwent surgery for refractory TLE during the 8-year study period, there were 34 (8.3%) patients with temporal lobe neoplasms. The median age at surgery was 20 years and the median duration of epilepsy prior to surgery was 9.0 years. MRI revealed tumor in the mesial location in 21 (61.8%) patients. Interictal and ictal epileptiform EEG abnormalities were localized to the side of th lesion in the majority. Mesial temporal lobe structures were included in the resection, if they were involved by the tumor; otherwise, lesionectomy alone was performed. During a median follow-up of 4 years, 27 (79%) patients were completely seizure-free. The only factor that predicted long-term seizure-free outcome was being seizure-free during the first two postoperative years. CONCLUSIONS: Our results emphasize the fact that in patients with tumoral TLE, when the seizures are medically refractory, surgery offers potential for cure of epilepsy in the majority.     

Seizure freedom off antiepileptic drugs after temporal lobe epilepsy surgery.

Data are limited on seizure recurrence after antiepileptic drug (AED) discontinuation in operated seizure-free patients. We reviewed seizure outcome in patients who came off AEDs after being seizure-free for 2 years following temporal lobe surgery in our center. Thirty-nine (68%) of 57 patients who discontinued AED therapy remained seizure-free. They had a younger age at surgery than the group with seizure recurrence (p=0.01). Earlier surgery may be a favorable predictor for seizure freedom after AED discontinuation.     

Uncontrolled epilepsy following discontinuation of antiepileptic drugs in seizure-free patients: a review of current clinical experience

PURPOSE: We reviewed the impact of planned discontinuation of antiepileptic drugs (AEDs) in seizure-free patients on seizure recurrence and the seizure outcome of reinstituted treatment. METHODS: A literature review was performed yielding 14 clinical observations of seizure recurrence after discontinuation and its treatment outcome. RESULTS: Seizure recurrence rate after AED discontinuation ranged between 12 and 66% (mean 34%, 95%CI: 27-43) in the 13 reviewed studies (no data in one study). Reinstitution of AEDs after recurrence was efficacious between 64-91% (mean of 14 studies, 80%, 95%CI: 75-85%) at follow-up. Mean follow-up ranged from 1-9 years. Seizure outcome of resumed treatment was not different for series in children and adolescents (84%, mean of 4 studies, 95%CI: 75-93) or in adults only (80%, mean of 9 studies, 95%CI: 74-86). Although seizure control was regained within approximately one year in half of the cases becoming seizure free, it took some patients as many as 5-12 years. In addition, in 19% (mean of 14 studies, 95%CI: 15-24%), resuming medication did not control the epilepsy as before, and chronic drug-resistant epilepsy with many seizures over as many as five years was seen in up to 23% of patients with a recurrence. Factors associated with poor treatment outcome of treating recurrences were symptomatic etiology, partial epilepsy and cognitive deficits. CONCLUSIONS: These serious and substantial risks weigh against discontinuation of AEDs in seizure-free patients, except perhaps for selected patients with idiopathic epilepsy syndromes of childhood or patients with rare seizures.     

How effective is surgery to cure seizures in drug-resistant temporal lobe epilepsy?

It is well recognized that two-thirds of patients with drug-resistant temporal lobe epilepsy will be free of disabling seizures with continued medical treatment after temporal resection. Seizure recurrence has been noted during a five-year follow-up in approximately one-third of these seizure-free patients mostly but not exclusively following planned complete discontinuation of antiepileptic drugs (AEDs). This leaves one-third of patients without disabling seizures and without AEDs several years after surgery. Despite improvements in seizure frequency or severity, seizures persist in another third of patients undergoing surgery. Although cure (five years without any seizures and off AEDs) is the ultimate aim of epilepsy surgery, the percentage of patients cured by surgery cannot be well defined at the moment. We need a long-term randomized controlled trial on AED discontinuation in seizure-free patients followed by long-term open extension to determine if only one in three adult patients with drug-resistant temporal lobe epilepsy is cured by surgical intervention.     

Temporal lobe epilepsy surgery: outcome, complications, and late mortality rate in 215 patients

PURPOSE: We studied the surgical outcome, complications, and the late mortality rate in a large group of patients with medically refractory temporal lobe epilepsy (TLE). METHODS: Two-hundred fifteen patients with TLE were treated surgically between 1984 and 1999 after a comprehensive presurgical evaluation. Patients were followed up at 6 weeks, 3-6 months, and yearly thereafter. In addition, questionnaires were sent on the anniversary of their surgery. Surgical outcome (Engel's classification), complication rate, and factors contributing to late mortality were analyzed. Standardized mortality ratios (SMRs) were calculated. RESULTS: There was no surgical mortality. Two (0.9%) had mild hemiparesis, one (0.4%) had a hemianopia, seven (3.2%) had transient cranial nerve palsies, and eight (3.7%) had transient postoperative language difficulties. One hundred forty-eight (69%) became seizure free, 43 (20%) had rare seizures, 14 (6.5%) had worthwhile seizure reduction, and 10 (4.6%) had no improvement (follow-up, 1-15 years). Three (2%) of 148 seizure-free patients died during follow-up, compared with eight (11.9%) of 67 not seizure-free patients. The mean duration of epilepsy before surgery for the surviving patients was 17.8 years, and for those patients who died, 25.9 years (p < 0.05). Six (5.7%) of 104 patients with right-sided resections died during follow-up, compared with five (4.5%) of 111 with left-sided resections. CONCLUSIONS: Eighty-nine percent of patients became seizure free or had rare seizures, with low morbidity, and no surgical mortality. The late mortality occurred predominantly in patients with persistent seizures (SMR, 7.4). Those patients who died had a longer duration of epilepsy before surgery. In contrast, among those patients who became seizure free, the mortality rate was much lower, and similar to the general population of Indiana (SMR, 1.7).     

Failed surgery for temporal lobe epilepsy: predictors of long-term seizure-free course

OBJECTIVES: To identify prognostic factors which predict the outcome 2 years after TLE surgery in those patients who were not seizure-free at the 6-month postoperative examination. METHODS: We included 86 postoperative TLE patients who had undergone presurgical evaluation, including video-EEG and high-resolution MRI, and who had seizures between the second and sixth postoperative months. RESULTS: 32% of patients were seizure-free in the second postoperative year. We found that normal MRI findings and secondarily generalized seizures (SGTCS) preoperatively were associated with a non-seizure-free outcome, while rare postoperative seizures and ipsilateral temporal IED with seizure-free outcome. Newly administered levetiracetam showed a significant positive effect on the postoperative outcome independent of other prognostic factors. Five of seven patients who received levetiracetam became seizure-free (p = 0.006). CONCLUSION: One-third of patients who did not become seizure-free immediately after surgery, eventually achieved long-term seizure freedom. We suggest watching for long-term seizure freedom after failed epilepsy surgery especially in patients who had rare postoperative seizures, focal MRI abnormality, ipsilateral temporal spikes, or no SGTCS preoperatively. Levetiracetam may have a positive effect on postsurgical seizures.     

Outcome After Discontinuation of Antiepileptic Drug Therapy in Children with Epilepsy

We studied recurrence risks and predictive factors of relapse after antiepileptic drug (AED) discontinuation in a prospective analysis of 425 children with epilepsy who had not had a seizure for at least 2 years (follow-up after withdrawal 1.6-12 years, mean 8 years). Factors closely related by multivariate analysis to relapse were neurologic abnormalities, mental retardation, seizure type (infantile spasms, absence seizures), and appearance or persistence of EEG abnormalities during the course of the illness and before discontinuation. When multivariate analysis was performed to evaluate outcome of patients with a first relapse (isolated vs. multiple relapses), the variables closely related to a poor prognosis were etiologic factors, first relapse characterized by more than one seizure in a 24-h period, seizure-free period less than 4 years, unchanged seizure type at first relapse, more than one AED for seizure control, and abnormal EEG before the first relapse. In itself, resumption of therapy did not influence outcome. At the study cutoff point, 88% of patients with relapse were again seizure-free. We conclude that AEDs can safely be discontinued if predictive factors are considered to individualize the risk of relapse for each patient.     

The chance of cure following surgery for drug-resistant temporal lobe epilepsy. What do we know and do we need to revise our expectations?

Although surgery is often seen as a curative treatment for patients with drug-resistant temporal lobe epilepsy, little information is available how many cases can be considered cured after surgery, i.e. are seizure-free for several years without taking antiepileptic drugs (AEDs). In our review, 13 retrospective and five prospective clinical observations published since 1980 provided data on long-term seizure control off AEDs in a total of 1658 patients. No randomized studies were found. Following temporal lobe surgery, approximately one in four adult patients and approximately one in three children or adolescents can currently shown to be seizure-free for 5 years without AEDs (25%, mean of eight studies in adults, 95% CI: 21–30%, and 31%, mean of three studies in children, 95% CI: 20–41%). The rate of seizure control off AEDs seemed to be stable after 2 years of follow-up. However, as 55% of patients free of disabling seizures preferred not to discontinue their medication completely as late as 5 years after surgery, it is impossible to know if they are cured or not. No features predictive of surgical cure were detected except for better cure outcome in children versus adults with hippocampal sclerosis and in patients with typical versus atypical Ammonshorn's sclerosis or tumor in one small study each. In conclusion, the available evidence on seizure outcome off AEDs after temporal lobe surgery is based on non-randomized studies and, in part, data were collected retrospectively. A randomized controlled trial is needed to determine if, in fact only one in three to four patients with temporal lobe epilepsy undergoing surgery can be considered cured.     

Antiepileptic drug treatment in seizure-free mesial temporal lobe epilepsy patients with hippocampal sclerosis following selective amygdalohippocampectomy

Retrospectively we analysed postoperative AED treatment in patients with mesial temporal lobe epilepsy and hippocampal sclerosis (MTLE-HS) who were seizure free following selective amygdalohippocampectomy (AHE). In this subgroup, we compared the patients without AEDs with that in the entire series. RESULTS: During the year prior to surgery, in the MTLE-HS group, a mean of 2.3 +/- 0.8 AEDs were taken. The percentage of seizure-free MTLE-HS patients without AEDs increases to 40% from the postoperative year 5 on. In the ILAE Class 1a (seizure- and aura-free since surgery) at postoperative year 5 more than 60% and from postoperative year 7 on more than 90% have discontinued AED intake. CONCLUSION: These figures indicate that reduction and discontinuation of AEDs is the same in the subgroup "seizure-free MTLE-HS patients" compared to the entire series.     

Hypersalivation in temporal lobe epilepsy

PURPOSE: We sought to determine whether hypersalivation helps lateralize seizure onset during complex partial seizures of temporal lobe origin. Several clinical signs, which help lateralize seizure onset, have been reported in temporal lobe epilepsy (TLE). Increased salivation only occasionally has been reported as a manifestation of partial epilepsy. METHODS: Of 590 consecutive patients admitted for video-EEG monitoring, either as a part of a presurgical evaluation of medically intractable epilepsy or for diagnosis and clarification of their paroxysmal symptoms, we identified 10 patients with ictal hypersalivation as a prominent manifestation of complex partial seizures. We reviewed the clinical features, scalp-sphenoidal video-EEG monitoring, intracarotid amytal (Wada) testing, hippocampal volumetric magnetic resonance imaging (MRI), and fluorodeoxyglucose-positron emission tomography (FDG-PET) scans of these patients. RESULTS: Of the 10 patients with ictal hypersalivation, seven patients had nondominant/right TLE, and three patients had dominant/left TLE. All patients had hippocampal atrophy on volumetric MRI. Eight of the 10 patients underwent standard temporal lobectomy with amygdalohippocampectomy (six right, two left). All of the operated-on patients had a seizure-free (Engel class I) outcome, and their increased salivation resolved. Two patients, who did not undergo surgical treatment, continue to have complex partial seizures with increased salivation. CONCLUSIONS: We conclude that increased salivation as a prominent ictal finding in complex partial seizures of temporal lobe origin is more likely to be of nondominant temporal lobe origin. Further studies with larger numbers of patients are needed to replicate this finding.     

Implications of Seizure Termination Location in Temporal Lobe Epilepsy

Summary: Where propagating symptomatic seizures terminate has not been studied, but might provide insight into mechanisms of seizure termination as well as localization of epileptogenic tissue. We investigated location of seizure termination in 50 refractory temporal lobe epilepsy (TLE) patients who had intracranial EEG recording of spontaneous seizures and subsequent temporal lobe resection with > 1–year follow-up. Only seizures that had onset in the resected temporal lobe were included. Location of the electrical termination for each seizure in each patient was categorized as diffuse, localized to the onset location, or localized elsewhere. The proportion of all seizures in each patient in each category was analyzed with respect to the outcome of surgery. Outcome was classified as seizure-free or persistent seizures. Diffuse seizure termination was noted equally frequently in both outcome groups. However, the 27 patients without seizures postoperatively had a significantly greater proportion of seizures with termination in the onset location (67%) than did the 23 patients with persistent seizures (36%, p < 0.01). The seizure-free patients also had a significantly lower proportion of seizures with localized termination elsewhere than the onset site (13%) than did patients with persistent seizures (45%, p < 0.005). Localization of the site of termination of seizures of focal origin to cortical regions other than the onset is associated with a poorer surgical prognosis. This observation raises the possibility of additional abnormal epileptogenic cortical regions with impaired seizure-terminating capabilities.     

Early antiepileptic drug reduction following anterior temporal lobectomy for medically intractable complex partial epilepsy.

PURPOSE: To determine the safety, in our practice, of allowing patient preference to influence the timing of antiepileptic drug (AED) reduction, once they became seizure-free after anterior temporal lobectomy (ATL). METHODS: Thirty patients underwent anterior temporal lobectomy for medically intractable complex partial epilepsy at Loma Linda University Medical Center between December 1st 1991 and November 30th 2001. Timing of AED reduction in seizure-free patients was based on patient request. A review of patient records noted seizure status, duration from surgery to AED reduction, AED side effects, seizure recurrence and whether control was regained. RESULTS: Twenty-four (80%) of the 30 patients became seizure-free on their preoperative AEDs after initial ATL; three additional patients after a second operation. AEDs were not reduced in the reoperated patients, the three patients who did not become seizure-free, and in two patients who asked to increase AEDs to control auras. Thus, AEDs were reduced in 22 of the 27 seizure-free patients. Patients were followed an average of 3.4 +/- 2.7 (mean +/- standard deviation) years. AED reduction was initiated 4.6 +/- 7.2 months (range 0-27 months) after surgery. Polytherapy use decreased from 54% preoperatively to 18% at last follow up. Seizures recurred in six patients (27% of 22); three became seizure-free after AED adjustments. CONCLUSIONS: In our practice, using an individualized approach to AED reduction following successful epilepsy surgery resulted in early reduction in AEDs. Our data suggest that early AED reduction can be performed safely and without undue risk of seizure recurrence.     

Temporallappenepilepsie Längsschnittliche klinische, neuropsychologische und psychosoziale Entwicklung operativ und konservativ behandelter Patienten

Little is known about the differential long-term outcome from surgical and nonsurgical therapy in patients with chronic epilepsy. In the present study, 161 surgically or nonsurgically treated patients with drug-resistant temporal lobe epilepsy (TLE) were re-evaluated according to a detailed clinical, neuropsychological, and psychosocial protocol with a mean follow-up interval of 58 months. Freedom from seizures was achieved in 64% of the surgical group; yet 23% of the nonsurgical patients became seizure-free as a result of modifications in drug therapy. Generally, socioeconomic development was poorer in nonsurgical than in surgical patients. Freedom from seizures, employment, and the absence of depression were significant determinants of better quality of life. As for neuropsychological outcome, verbal memory impairment was common after left-sided temporal resection; however, there was no evidence of a marked progression of cognitive impairment after the first postoperative year. In nonsurgical patients, too, cognitive capacities were surprisingly stable over time, although persisting seizures and good baseline performance predicted a poorer neuropsychological outcome.