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Venteicher_Stanford_MGH_No_Movies_072010.pptx - Slide 1 Venteicher_Stanford_MGH_No_Movies_072010.pptx - Slide 1 Presentation Transcript

  • Patient JA: Surgery for temporal lobe epilepsy
    Andrew Venteicher
    Visiting sub-intern
    Stanford University
    July 2010
  • Patient JA
    ID/CC: 24yo right-handed F with medically refractory epilepsy
    HPI:
    2001: right temporal craniotomy for partial resection of epidermoid cyst of CP angle
    2001 – 2010:
    • first seizure was on POD 0
    • on medication, she has weekly episodes of strange noise and taste in her mouth followed by LOC, vocalizations, repetitive oral movements, and convulsive activity.
    • incomplete seizure control on trials of oxcarbazepine, lamotrigene.
    • embarrassing post-ictal behavior, afraid to leave her house.
    • on disability for epilepsy.
  • Patient JA (cont)
    PMH/PSH: C-section 2004
    Allergies: phenytoin
    Outpatient meds: topiramate 200mg BID, levetiracetam 1000mg BID
    FH: No history of CNS tumors, seizure disorder.
    SH: Seven-month old daughter. Daily marijuana, no other drug use.
    ROS: Poor memory, depressed mood.
    Exam: Memory: 2/3 at five minutes
    Unable to perform simple arithmetic (may be secondary to effort)
    Otherwise neurologically intact (CN, motor, sensory, cerebellar, reflexes)
  • Pre-op MRI: Axial
    T2
    • T2 hyperintensity of right inferior and middle temporal gyri,
    correlated well with epileptiform discharges on EEG/MEG
    • Progression of incompletely resectedepidermoid
    of right cerebellopontine angle, relative to MRIs at outside
    hospital
  • Pre-op MRI: Coronal
    FLAIR
    T1 post-gad
    • Hyperintensity on FLAIR of right inferior temporal lobe
    • Non-enhancing right pontine lesion
  • Operative plan
    Resection for epileptic focus:
    Right anterior temporal lobectomy
    2. Microscopic dissection of epidermoid
  • 1. Resection of epileptic focus
    Neocortical structures
    • Corticoectomy of middle temporal gyrus
    • Extended inferiorly to middle fossa floor
    • Extended anteriorly to temporal tip
    • Removed anterior 2cm of superior temporal lobe
    Mesiotemporal structures
    • Entered temporal horn of lateral ventricle to access hippocampus
    • Interoperativecorticography: eight-lead electrode recorded frequent spikes from anterior hippocampus
    • Anterior hippocampus and amygdalaresected
    • Entered medial pia to access ambient cistern
    Netter
    Dr. Nahed/Dr. Eskandar
  • 2a. Initial resection of epidermoid
    • Approach through
    medial aspect of
    temporal lobe
    • Gross: encountered
    pearly white mass
    • Path: stratified
    squamous epithelium,
    keratin, cholesterol
    • Rad: T1 dark, T2 bright,
    typically no enhancement
    A
    P
    Dr. Nahed/Dr. Eskandar
  • 2b. Dissection to anterior pons
    • Approach through
    medial aspect of
    temporal lobe
    • Gross: encountered
    pearly white mass
    • Path: stratified
    squamous epithelium,
    keratin, cholesterol
    • Rad: T1 dark, T2 bright,
    typically no enhancement
    A
    P
    Dr. Nahed/Dr. Eskandar
  • 2c. Resection of tumor off basilar artery
    • Approach through
    medial aspect of
    temporal lobe
    • Gross: encountered
    pearly white mass
    • Path: stratified
    squamous epithelium,
    keratin, cholesterol
    • Rad: T1 dark, T2 bright,
    typically no enhancement
    A
    P
    A
    P
    Dr. Nahed/Dr. Eskandar
  • Post-operative course
    • Maintained on home doses of topiramate and levetiracetam
    • Interval development of superior quadrantanopsia
    Pre-op
    Post-op
  • Temporal lobe epilepsy
    Background
    Choosing a surgical approach
  • Background: Temporal lobe epilepsy
    • 20-40% of epilepsy patients have medically refractory epilepsy
    (400,000 patients in the U.S.)
    • Etiologies:
    Mesial temporal sclerosis
    Infections: Systemic, CNS
    Vascular: AVMs, cavernomas
    Neoplasia
    Congenital: cortical dysplasias
    Traumatic: TBI, post-operative
    Genetics
    • Familial lateral temporal lobe epilepsy
    with auditory features (AD)
    • Familial mesial temporal lobe epilepsy (usually AD)
    • Indications for surgery: medically refractory, negatively
    impacts patient’s quality of life
    Up To Date 2010.
  • Background: Surgery for temporal lobe epilepsy
    - 80 patients randomized
    - median of 5 seizures/month
    - complications: 55% surgical group developed VF defect (rare memory deficit, infarct, infection)
    Wiebe et al. NEJM 2001.
  • Choosing the surgical approach
    Outcomes:
    Seizure frequency
    Neuropsychological outcomes
    Approaches:
    Anterior temporal lobectomy
    ATL with sparing of superior temporal gyrus
    Selective amygdalo-hippocampectomy
    Controversial:
    Variety of approaches
    Lack of randomized trials
    Schramm. Epilepsia 2008.
  • Three RCTs of surgical approaches:
    1. ATL with partial or full hippocampectomy
    Patients: 70.
    Subjects: age 18-40 , complex partial seizures,
    originate from medial temporal lobe (EEG), IQ > 69, no foreign lesions
    Operation: ATL of 4.5cm (superior, middle, and inferior), with either partial or full hippocampectomy
    Results: - At one year, 69% (total) versus 38% (partial) were seizure-free after surgery
    - At 6 months, no difference in several memory tests
    Wyler et al. Neurosurgery 1995.
  • Three RCTs of surgical approaches:
    2. Left ATL +/- sparing of superior temporal gyrus
    Patients: 28.
    Subjects: complex partial seizures, originate from left temporal lobe (EEG), left dominant (WADA), IQ > 69,
    no foreign lesions
    Operation: ATL of 4-4.5cm of middle/inferior temporal lobe +/- STG,
    with full hippocampectomy
    Results: - At 6-8 months, no difference in proportion seizure-free (60% vs 55%)
    - At 6-8 months, no difference in change in visual naming ability
    Hermann et al. Epilepsia1999.
  • Three RCTs of surgical approaches:
    Transsylvianvstranscortical approach for SAH
    Patients: 80.
    Subjects: diagnosis of hippocampal sclerosis,
    age > 16, IQ > 69, not left-handed
    Operation: transsylvian – pterionalcrani then through lateral ventricle
    transcortical – crani centered on MTG
    Results: - Variety of tests: memory, attention, and executive function
    - 73% vs 77% were seizure -free at 7 months (NS)
    - word fluency improved only in pts with transcortical approach (no other differences in many other tests)
    Transsylvian - UC Irvine website
    Lutz et al. Epilepsia2004.
  • Three RCTs of surgical approaches
    First author Journal / Year Pts Operation Outcomes
    Wyler Neurosurgery 70 ATL + full or 69% vs 38% seizure-free at 1 yr
    1995 partial hippocampect. No difference in memory
    Hermann Epilepsia 30 Left ATL 60% vs 55% seizure-free (N.S.)
    1999 + / - STG resection No change in naming
    Lutz Epilepsia 80 transcorticalvs 75% seizure-free at 7 months
    2004 transsylvian AH (no difference)
    Slight difference in neuropsych
    • Tailor to experience of surgeon/institution
    • Tailor to patient’s pre-op localization studies
    • More RCTs may be helpful, incorporating QOL/neuropsychologic outcomes
  • Thank you
  • Pre-operative planning
    Mesial temporal lobe epilepsy (MTLE)
    • Most common indication for epilepsy surgery
    • “Mesial auras” – rising epigastrium, olfactory/gustatory, and fear
    • MRI: volume loss and T2/FLAIR hyperintensity in hippocampus
    Neocortical temporal lobe epilepsy (NTLE)
    • Rarer
    • “Lateral auras” – auditory, visual, somatosensory
    • Usually structural : post-trauma, tumor, vascular malformation
    Pre-op assessment
    • Interdisiplinary team
    • MRI w/ and w/o contrast
    • EEG, MEG, video-EEG
    • Neuropsychological testing
    Up To Date 2010.
    Berg. Curr Op Neurol 2008.
    Bender. J Neurosurg 2009.
  • “Quest for optimal resection”
    • Controversial
    • Few randomized trials
    • Variety of methods
    Schramm. Epilepsia2008.
  • Pre-op EEG/MEG
    • Left-dominant language center
    • Right >> left temporal interictal
    epileptiform discharges
    • Discharges correlate to T2 signal abnormalities in right temporal lobe
    Papaniculaou et al.
    J Neurosurg1999.