The longitudinal course of adjustment after seizure surgery.

Surgical alleviation of chronic epilepsy can give rise to a process of adjustment as the chronically ill patient learns to become well. This process can manifest clinically as an array of symptoms which we have previously described as the 'burden of normality'. The aim of this study was to explore the longitudinal course of post-operative adjustment by mapping the incidence of symptoms of the burden of normality over a period of 2 years, and examining symptom occurrence relative to seizure outcome. A series of 90 anterior temporal lobectomy (ATL) patients was drawn from our Seizure Surgery Follow-up and Rehabilitation Program. All patients were prospectively assessed using the Austin CEP Interview, which covers symptoms of the burden of normality. In total, 66% of patients reported symptoms at some time within the first 2 years of surgery. Symptoms often emerged by the 3 month review, but were still seen frequently in the second year. At the 24 month review, patients who had been seizure free or experienced auras only within the previous 18 months were significantly more likely to report symptoms compared to patients who had experienced complex partial and/or generalized tonic-clonic seizures (P = 0.03). Surgical alleviation of seizures in chronic epilepsy brings with it the burden of normality. Recognition of this syndrome is essential in maximizing patient outcome.     

Psychosocial adjustment following relief of chronic narcolepsy

BACKGROUND AND PURPOSE: No previous research has examined the psychosocial adjustment of chronic narcolepsy patients following efficacious pharmacotherapy. In contrast, considerable research has examined the process of psychosocial adjustment following surgical relief of chronic epilepsy. This process can manifest as a clinical syndrome, the 'burden of normality', comprising psychological, behavioural, affective and sociological features. The aim of the present study was to characterise the process of psychosocial adjustment of patients with successfully treated narcolepsy and to explore the applicability of the burden of normality. PATIENTS AND METHODS: Thirty-three narcolepsy patients and 31 epilepsy surgery patients were recruited through routine outpatient follow-up at the Austin Hospital in Melbourne. All patients underwent in-depth, qualitative psychosocial assessment using a well-validated semi-structured interview, the Austin CEP Interview. They were also administered quantitative measures of anxiety (State Trait Anxiety Inventory) and depression (Beck Depression Inventory-II). RESULTS: Narcolepsy patients spontaneously reported similar themes of post-treatment adjustment to successfully treated epilepsy patients, including symptoms of the burden of normality. Chi-squared analyses revealed that the two groups differed only on disease-specific factors, reflecting the later diagnosis and treatment of narcolepsy (P<0.05). CONCLUSION: The results support a general model of adjustment following successful treatment of chronic neurological illness, as the patient discards perceptions of illness and behaviours associated with being 'sick' and learns to become 'well'. Recognition of the burden of normality has important clinical implications for maximising the post-treatment care and outcome of narcolepsy patients.     

Preoperative psychological adjustment and surgical outcome are determinants of psychosocial status after anterior temporal lobectomy.

This investigation evaluated the role of preoperative psychological adjustment, degree of postoperative seizure reduction, and other relevant variables (age, education, IQ, age at onset of epilepsy, laterality of resection) in determining emotional/psychosocial outcome following anterior temporal lobectomy. Ninety seven patients with complex partial seizures of temporal lobe origin were administered the Minnesota Multiphasic Personality Inventory (MMPI), Washington Psychosocial Seizure Inventory (WPSI), and the General Health Questionnaire (GHQ) both before and six to eight months after anterior temporal lobectomy. The data were subjected to a nonparametric rank sum technique (O'Brien's procedure) which combined the test scores to form a single outcome index (TOTAL PSYCHOSOCIAL OUTCOME) that was analysed by multiple regression procedures. Results indicated that the most powerful predictors of patients' overall postoperative psychosocial outcome were: 1) The adequacy of their preoperative psychosocial adjustment, and 2) A totally seizure-free outcome. Additional analyses were carried out separately on the MMPI, WPSI, and GHQ to determine whether findings varied as a function of the specific outcome measure. These results were related to the larger literature concerned with the psychological outcome of anterior temporal lobectomy.     

Psychological adjustment to success and to failure following epilepsy surgery

Treatment-refractory epilepsy can directly impair psychological adjustment and quality of life. Epilepsy surgery is viewed by the patient as a stressful life event, arrived at after extensive deliberation. It is accompanied by expectations and anxiety for patients and their families. We suggest that the success of epilepsy surgery (as reflected by patient-perceived impact on quality of life) depends not only on reduced seizure frequency, but on personality factors and psychosocial issues. This paper reviews our research on these factors, along with suggestions for psychological assessment (of quality of life, and of personality) and psychological treatment. Studies of quality of life in patients undergoing temporal lobectomy are also examined. Finally, factors leading to the perception of "failed" epilepsy surgery are considered, along with suggested ways to manage such cases.     

Predicting the psychosocial outcome of epilepsy surgery: A longitudinal perspective on the ‘burden of normality’

Good seizure outcomes and good psychosocial outcomes following epilepsy surgery do not necessarily follow one from the other. This study explored the relationship between several presurgical psychosocial characteristics and postsurgical quality-of-life outcomes. The study aimed to develop the concept of ‘the burden of normality’ and identify risk factors for a poor psychosocial outcome that could be targeted with ameliorative presurgery cognitive behavioral techniques. Data were collected from 77 epilepsy surgery patients from three UK epilepsy centers and presurgery and postsurgery follow-up data were obtained from 30–34 patients, depending on the measure. Measures were self-report. Postsurgery intervals were determined by the epilepsy surgery care pathway at individual centers. Presurgery poor levels of mental health, poor social functioning, increased belief in illness chronicity, and associating epilepsy with social role limitations were all associated with poor postsurgical quality of life. Adopting an accepting coping strategy presurgery was associated with good postoperative quality of life. Regression analysis showed that a good postsurgical quality of life was positively predicted by a presurgical coping style of being able to make the best of a situation and see challenges in a positive light (i.e., positive reinterpretation and growth from the COPE scale) and negatively predicted by presurgical levels of anxiety. These data are presented as an important step in identifying psychological red flags for an adverse psychosocial outcome to epilepsy surgery, as exemplified by the concept of the ‘burden of normality’ and specifying targets for preoperative ameliorative psychological advice.     

Moderators of the effect of preoperative emotional adjustment on postoperative depression after surgery for temporal lobe epilepsy

PURPOSE: Other outcome measures besides seizure control must be considered when assessing the benefit of epilepsy surgery. We investigated the effect of preoperative psychosocial adjustment on postoperative depression in epilepsy patients followed up prospectively for 2 years after temporal lobectomy. METHODS: The Washington Psychosocial Seizure Inventory (WPSI) evaluated psychosocial functioning; the Centre for Epidemiological Studies Depression Scale (CES-D) measured depression. Both were completed at baseline and follow-up. RESULTS: Follow-up occurred in 39 temporal lobectomy patients at 2 years after surgery. Greatest improvement in depression scores was limited to patients with good seizure outcomes (seizure free, or marked reduction in seizure frequency), and seizure outcome was a significant predictor of postoperative depression. Despite this, preoperative scores on the emotional adjustment scale of the WPSI were most highly correlated with depression 2 years after surgery. To clarify this relation, moderated hierarchic regression suggested that good preoperative emotional adjustment (WPSI) was generally associated with less depression after surgery. Moreover, poorer preoperative adjustment combined with older age, generalized seizures, the finding of preoperative neurologic deficits, a family history of psychiatric illness, and/or a family history of seizures was related to higher depression scores 2 years after surgery. CONCLUSIONS: Depression after temporal lobectomy is dependent on a complex interaction of variables and can have a significant effect on indices of postoperative adjustment. The WPSI emotional adjustment scale may help to predict which patients are likely to be chronically depressed after surgery.     

Paradoxical results in the cure of chronic illness: the "burden of normality" as exemplified following seizure surgery

Little has been written about processes of recovery following life-changing medical interventions for chronic illness. This article reviews our research with chronic epilepsy patients undergoing neurosurgery for the relief of intractable partial seizures. This research has given rise to a new conceptualization of adjustment and outcome following effective treatment of chronic illness, representing the first, detailed characterization of this process from a psychological and psychosocial perspective. Crucial to outcome are patient and family expectations prior to treatment, and learning to discard roles associated with chronic illness after treatment. These and the posttreatment affective functioning of the patient temper the view of medical outcome, and can account for paradoxical clinical effects, such as worsening patient psychosocial functioning in the context of medical treatment success. Our results have clear implications for the clinical management of chronically ill patients and their families to optimize treatment outcome.     

Visual Confrontation Naming Outcome After Standard Left Anterior Temporal Lobectomy with Sparing Versus Resection of the Superior Temporal Gyrus: A Randomized Prospective Clinical Trial

PURPOSE: Intraoperative mapping of eloquent cortex during left (speech dominant) anterior temporal lobectomy has shown a significant proportion of patients to have sites on the anterior superior temporal gyrus at which visual confrontation naming can be disrupted by electrical stimulation. The purpose of this investigation was to conduct a randomized clinical trial to determine whether sparing versus resection of the superior temporal gyrus affected visual confrontation naming outcome after standard left anterior temporal lobectomy. Also examined was the degree to which inherent patient characteristics were associated with language outcome regardless of surgical technique. METHODS: Thirty patients with intractable left temporal lobe epilepsy undergoing standard anterior temporal lobectomy were randomized in regard to whether the superior temporal gyrus was resected or spared. Patients were tested preoperatively and 6-8 months postoperatively by using two conventional tests of visual confrontation naming ability. RESULTS: No significant differences were found between the groups in either confrontation naming or surgical outcome. Postoperative decline in nominal speech was most closely associated with later age at onset of epilepsy/absence of hippocampal sclerosis. CONCLUSIONS: It appears that specific types of localization-related temporal lobe epilepsy are more closely associated with the risk of adverse language outcome after anterior temporal lobectomy than with the surgical variations investigated in this study.     

儿童和青少年颞叶癫癎的术后长期疗效观察

目的总结儿童和青少年颞叶癫癎手术后的长期疗效和生活质量。方法回顾性分析31例儿童和青少年颞叶癫癎病人的临床资料,行标准前颞叶切除术26例,扩大前颞叶切除术2例,前颞叶切除术＋软化灶切除术2例,颞后顶下致癎灶切除术1例。评估术后癫癎发作改善情况及认知、生活质量等。结果术后随访5年以上,其中癫癎发作消失、达到EngelⅠ级26例,EngelⅡ级1例,EngelⅢ级2例,EngelⅣ级2例。术后病理示：海马组织硬化13例,皮质发育异常伴胶质增生9例,皮质发育异常伴海马组织硬化6例,神经元胶质肿瘤2例,继发性瘢痕脑回形成1例。术后并发症多数可恢复。结论儿童和青少年颞叶癫癎术后长期疗效良好,生活质量提高。     

Psychological outcome profiles in childhood‐onset temporal lobe epilepsy

Purpose: To examine the effect of childhood‐onset temporal lobe epilepsy (TLE) on long‐term psychological function and to identify outcome profiles related to the natural course and treatment of TLE. Methods: Psychological function was studied in a prospective, community‐based cohort of childhood‐onset TLE, approximately 13 years following seizure onset. Fifty‐three patients were assessed using a semi‐structured psychosocial interview, supplemented by self‐report questionnaires measuring quality‐of‐life, depression, self‐esteem, and anxiety. Results: Common patterns were observed, giving rise to four distinct patient groups and psychological outcomes: (1) patients who experienced spontaneous remission of their seizures fared best; their psychological profile was characterized by heightened worry about the possibility of seizure recurrence; (2) patients who progressed to surgery and were seizure free reported adjustment difficulties associated with learning to become “well”; (3) patients who progressed to surgery and were not seizure free had the poorest psychological outcomes, with depression featuring prominently; and (4) patients with ongoing intractable epilepsy reported psychological and social features consistent with the effects of their chronic illness. Discussion: Patients with childhood‐onset TLE face distinctive long‐term psychological challenges. The specific nature of these challenges can be understood in terms of the natural evolution and treatment of their epilepsy.     

术中皮层脑电图在颞叶癫痫手术中的应用

目的 探讨术中皮层脑电图(ECoG)在颢叶癫痫手术中的应用价值.方法 回顾性分析105例前颞叶切除手术患者的临床资料与ECoG的监测结果,统计对ECoG的影响因素及其对手术疗效的影响.结果 术前ECoG平均监测时间为72 min,结果显示:无异常11例、颢叶或前颞叶局限性放电73例、广泛痫性放电21例;术后ECoG平均监测时间为38 min,结果显示:无异常91例、颞叶后部痫性放电9例、广泛痫性放电5例.年龄与术前EcoG结果无明显相关性;而病程＜5年者术前EcoG痫性放电局限于前颞叶的比率较高,达到83.3%,且与另外两组差异有统计学意义.有6例(5.7%)根据术后ECoG结果行颞叶皮层后部扩大切除.术前ECoG显示痫性放电局限于前颞叶和术后ECoG正常与其他同期结果间的手术疗效差异有统计学意义,提示术后无癫痫发作.结论 颞叶癫痫患者ECoG监测可发现70%的痫波局限于前颞区,术前和术后ECoG监测结果可用于初步判断手术疗效,ECoG监测对颞叶癫痫手术具有一定的应用价值.     

Outcome assessment in seizure surgery: The role of postoperative adjustment

The usual criteria employed in assessing the outcome of seizure surgery is almost always that of success in abolition of seizures. Whilst this is a logical method of assessment, experience with large series of such patients shows that this is by no means the only significant criterion. Here we examine the process of postoperative adjustment and the role it plays in determining the outcome of temporal lobectomy for refractory epilepsy. The specific domains involved in this process are examined and it is shown that in a number of cases what is thought to have been surgical success has in fact been significantly diminished by difficulties encountered in postoperative adjustment — to such an extent that total seizure abolition has not resulted in clinical advantage.     

Epilepsy surgery outcomes in temporal lobe epilepsy with a normal MRI

Purpose:   To determine the long-term efficacy of anterior temporal lobectomy for medically refractory temporal lobe epilepsy in patients with nonlesional magnetic resonance imaging (MRI).
Methods:   We identified a retrospective cohort of 44 patients with a nonlesional modern "seizure protocol" MRI who underwent anterior temporal lobectomy for treatment of medically refractory partial epilepsy. Postoperative seizure freedom was determined by Kaplan-Meyer survival analysis. Noninvasive preoperative diagnostic factors potentially associated with excellent surgical outcome were examined by univariate analysis in the 40 patients with follow-up of >1 year.
Results:   Engel class I outcomes (free of disabling seizures) were observed in 60% (24 of 40) patients. Preoperative factors associated with Engel class I outcome were: (1) absence of contralateral or extratemporal interictal epileptiform discharges, (2) subtraction ictal single photon emission computed tomography (SPECT) Coregistered to MRI (SISCOM) abnormality localized to the resection site, and (3) subtle nonspecific MRI findings in the mesial temporal lobe concordant to the resection.
Discussion:   In carefully selected patients with temporal lobe epilepsy and a nonlesional MRI, anterior temporal lobectomy can often render patients free of disabling seizures. This favorable rate of surgical success is likely due to the detection of concordant abnormalities that indicate unilateral temporal lobe epilepsy in patients with nonlesional MRI.     

Race/ethnicity: a predictor of temporal lobe epilepsy surgery outcome?

PURPOSE: The success of epilepsy surgery in temporal lobe epilepsy reaches a 64% rate of seizure freedom, based on a randomized control trial. Observational studies from epilepsy centers worldwide indicate seizure freedom rates up to 93% when the etiology is unilateral hippocampal sclerosis. Several risk factors are attributed to the recurrence of seizures following the surgical procedure. Nonetheless, whether race influences the outcome of temporal lobe surgery is unknown. The purpose of this study was to evaluate if race plays a role in outcome following surgery. METHODS: Data were obtained from the discharge database of the University of Alabama at Birmingham video/EEG monitoring unit, between 1998 and 2003, as well as the clinical charts. Seizure recurrence was evaluated 1 year following surgery. The sample consisted of all patients with a primary diagnosis of mesial temporal sclerosis (MTS) who underwent anterior temporal lobectomy. Multiple logistic regression analysis was used to model the presence of seizure recurrence after anterior temporal lobectomy for MTS. Two sets of logistic regression models were estimated to generate odds ratios (ORs) for seizure recurrence after an anterior temporal lobectomy for African-Americans or other possible ethnic/racial group present relative to non-Hispanic Caucasians. The first model incorporated only ethnicity as the independent variable and generated unadjusted ORs for seizure recurrence following the surgical procedure. The second set included the independent variables: duration of epilepsy, history of febrile seizures, lateralization of epileptogenic focus, handedness, and age. RESULTS: Seventy patients underwent surgical treatment and all of them had pathologic confirmation of MTS. Follow-up information for six was not available. Analysis of the remaining 64 patients revealed that African-Americans were more likely than non-Hispanic Caucasians to have seizure recurrence after surgery (OR=2.1, 95% CI=0.6-8.0). After potential confounders (duration of epilepsy, history of febrile seizures, lateralization of epileptogenic focus, handedness, and age) were controlled, this finding did not change (OR=1.7, 95% CI=0.3-10.7). CONCLUSION: Our data suggest that race may be an important factor related to seizure outcome following temporal lobectomy.     

Epilepsy with temporal encephalocele: Characteristics of electrocorticography and surgical outcome

Temporal lobe encephaloceles (TEs) are increasingly identified in patients with epilepsy due to advances in neuroimaging. Select patients become seizure‐free with lesionectomy. In practice, however, many of these patients will undergo standard anterior temporal lobectomy. Herein we report on the first series of patients with refractory temporal lobe epilepsy (TLE) with encephalocele to undergo chronic or intraoperative electrocorticography (ECoG) in order to characterize the putative epileptogenic nature of these lesions and help guide surgical planning. This retrospective study includes nine adult patients with magnetic resonance imaging/computed tomography (MRI/CT)–defined temporal encephalocele treated between 2007 and 2014 at University of California San Francisco (UCSF). Clinical features, ECoG, imaging, and surgical outcomes are reviewed. Six patients underwent resective epilepsy surgery. Each case demonstrated abnormal epileptiform discharges around the cortical area of the encephalocele. Two underwent tailored lesionectomy and four underwent lesionectomy plus anterior medial temporal resection. Postoperatively, five patients, including both with lesionectomy only, had Engel class Ia surgical outcome, and one had a class IIb surgical outcome. The role of TE in the pathogenesis of epilepsy is uncertain. ECoG can confirm the presence of interictal epileptiform discharges and seizures arising from these lesions. Patients overall had a very good surgical prognosis, even with selective surgical approaches.     

Significance of cerebellar atrophy in intractable temporal lobe epilepsy: a quantitative MRI study

PURPOSE: To determine the incidence of cerebellar atrophy (CA) in patients with intractable temporal lobe epilepsy, whether any clinical factors are significantly associated with CA, whether CA is unilateral or asymmetric and whether this feature has any relationship to the side of epileptogenicity, and whether the presence of CA is related to epilepsy surgery outcome. METHODS: We developed a magnetic resonance imaging method of measuring the presurgical volumes of the cerebellar hemispheres of 185 patients who underwent temporal lobectomy for intractable epilepsy and of 80 control subjects. In addition, cerebellar volumes were normalized to the total brain volumes. CA was determined as being present when the measured volume was smaller than two standard deviations from the mean value found in control subjects. RESULTS: Both absolute and normalized cerebellar volumes were found to be significantly reduced in the epilepsy patients compared with the control subjects. Without normalization of the cerebellar volumes, CA was present in 25.9% of the epilepsy patients; with normalization, it was present in only 16.2%. The atrophy was symmetric between the cerebellar hemispheres, and there was no significant difference in volume between the hemisphere ipsilateral and the hemisphere contralateral to the side of the temporal lobectomy. The duration of epilepsy was significantly longer and the age at onset of epilepsy was younger in patients with CA than in those without CA. The presence of CA was not associated with the outcome of temporal lobectomy. CONCLUSIONS: CA is symmetric and common in patients with intractable temporal lobe epilepsy. However, the results suggest that the atrophy in one third of patients with CA also proportionately affects the cerebral hemispheres. The duration of epilepsy and the age at onset of epilepsy are associated with the occurrence of CA. Seizure control after temporal lobectomy is not influenced by the presence of CA.     

Improvement of Quality-of-Life following Resective Surgery for Temporal Lobe Epilepsy: Results of Patient and Family Assessments

Abstract: In order to evaluate the quality-of-life (QOL) of epilepsy surgery patients, we surveyed patients' degree of life satisfaction and their families' degree of satisfaction with patient's status in a range of domains both pre- and post-operatively. Of 100 patient-family sets of surveys that were mailed out, 93 were completed and returned from patients and 91 from their families. All patients surveyed had temporal lobe epilepsy and had been followed for longer than 2 years after resective surgery. Patients and their families rated overall QOL as having markedly improved following surgery. However, they rated social domains of QOL, including role activities, financial status, and social and family relationships as having improved relatively little. Despite freedom from seizures, a few patients' families were dissatisfied with the patients' post-operative status, primarily for psychosocial reasons. Patients operated on at a later age reported little gains in life satisfaction following surgery. This study supports the conclusion that surgical intervention should occur before patients are subjected to the psychological conflicts and social handicaps associated with chronic intractable epilepsy.     

Psychiatric history does not predict seizure outcome following temporal lobectomy for mesial temporal sclerosis

Purpose: A lifetime psychiatric history has been reported to be associated with poorer seizure outcome following temporal lobectomy for drug‐resistant focal epilepsy, but it remains unclear whether this is confounded by the nature of the epileptogenic pathology. Here we examined this association in a pathologically homogeneous group of patients with mesial temporal sclerosis (MTS). Methods: The study population included 72 consecutive patients who underwent a temporal lobectomy for drug resistant temporal lobe epilepsy (TLE) and had histopathologically proven MTS. All patients were assessed preoperatively by a neuropsychiatrist. Chi‐square analysis was undertaken to look for demographic, clinical, psychiatric, or neurologic factors associated with seizure outcome at 1 year. The relationship between having a psychiatric disorder and seizure outcome was examined by generating Kaplan‐Meier curves and comparing between groups the log rank test as well as generating Cox regression models to estimate hazard ratios. Key Findings: There were no significant associations between postsurgery seizure outcome and a current or lifetime history of any psychiatric disorder. Significance: A history of psychiatric disorder, in particular depression and psychosis, is not associated with a poorer surgical outcome in patients with MTS. These findings have implications for the clinical management of patients under consideration for temporal lobectomy.     

Family Interactions as Targets for Intervention to Improve Social Adjustment After Epilepsy Surgery

PURPOSE: To identify family interactions associated with psychosocial outcome of epilepsy surgery, to design interventions to improve patient outcome. METHODS: A cross-sectional, case series study of relations among observed family behavior and psychosocial outcome of 43 patients after temporal lobectomy. Videotaped family behavior during family discussion tasks was rated for predominant family affect, affective range, and support of patient autonomy. Multiple regression analyses tested the relation of observed family characteristics to outcomes, controlling for seizure control and other psychological and disease characteristics. RESULTS: Predominant family affect predicted patients' social adjustment independent of postoperative seizure status and other disease characteristics. The relation between predominant affect and social adjustment was stronger among patients with persisting complex partial seizures (CPSs; r = -0.91), versus patients with auras (r = -0.38) and seizure-free patients (r = -0.28; multiple R = 0.71; p < 0.05). Families with a positive affective climate supported patients' autonomy. CONCLUSIONS: Two potential targets were identified for family intervention to improve postsurgical social adjustment: (a) family interactions that support a predominantly positive affective climate, and (b) family interactions that support patient autonomy. These findings are consistent with findings in normal and other clinical populations. They identify specific interactions that give rise to positive versus negative affective climate and support versus undermining of autonomy. These results lay the groundwork for intervention studies targeting these specific family interactions. Such intervention studies would clarify the direction of effect of the observed relationships and would test the efficacy of family intervention for improving psychosocial outcomes for patients with epilepsy.     

Causal attributions for seizures: Relation to preoperative psychological adjustment and postoperative psychosocial function in temporal lobe epilepsy

In a sample of 65 epilepsy patients who were temporal lobectomy candidates, the links between causal attributions, learned resourcefulness, and preoperative psychosocial adjustment were explored. In addition, attributions as predictors of objective 2-year postoperative psychosocial outcomes were examined prospectively. With illness severity controlled for, attribution of seizures to stress factors and low learned resourcefulness were predictive of poor psychosocial adjustment preoperatively. Taking personal responsibility for seizure occurrence (self-blame) was associated with better psychosocial adjustment. At 2 years, patients were divided into three groups: (a) postoperative seizure-free (n = 21), (b) postoperative not seizure-free (n = 19), and (c) nonoperated controls (n = 25). Seizure-free outcome status was associated with better psychosocial outcome. Of greater interest was the predictive value of preoperative attributions. As expected, attributions involving personal responsibility were predictive of postoperative full-time employment and receipt of disability benefits. The data enhance understanding of the ways in which patients with epilepsy manage the challenges they face and enhance the psychometric prediction of psychosocial behavioral outcomes after epilepsy surgery.