Temporal lobe epilepsy is one of the most common forms of epilepsy. It can be caused by hippocampal sclerosis or lesions in the temporal lobe. Hippocampal sclerosis involves neuronal loss and gliosis in the hippocampus and is the most common pathological finding in temporal lobe epilepsy patients. Interictal EEG findings like temporal intermittent rhythmic delta activity and temporal sharp waves help lateralize the seizure focus. Video EEG monitoring helps capture seizures and interictal discharges. Treatment involves antiepileptic drugs and potentially resective surgery for drug-resistant cases.

1. Temporal lobe epilepsy
Siva Pesala MD
Department of Neurology

2. Epilepsy
• “A condition characterized by two or more recurrent epileptic
seizures over a period longer than 24 hours, unprovoked by
any immediate identified cause”.
Ref-Jacobs et al., 2001

3. ILAE 2017 TLE

4. Temporal lobe epilepsy -Introduction
• The temporal lobe is the most epileptogenic region of
the human brain.
• Hippocampal sclerosis (HS) is the commonest cause of
TLE.
• It is estimated that it represents about 40% of all
epilepsies in adult people.
Tatum 2012- J Clinical neurophysiology, Cendes, 2005 & Blair, 2012

5. Epidemiology
• Per available epidemiological data on TLE, the Incidence rate
was 10.4 per 100,000 and the prevalence was 1.7 per 1000
people.
• They represent approximately two third of the intractable
seizure population requiring surgical management.
Hauser & Kurland, 1975, (Spencer & Spencer, 1985; Semah et al., 1998).

6. Types of TLE
• The ILAE (Commission on classification and terminology of the
ILAE, 1989) recognizes two syndromes.
• Mesial temporal lobe epilepsy( most frequent)
• Lateral or neocortical temporal epilepsy (NTE)

7. Mesial temporal lobe epilepsy
• Most common form of partial epilepsy in adolescents and
adults.
• These patients usually have known risk factors such as
perinatal injury, CNS infection, FS, head trauma, and fam h/o of
epilepsy .
• Up to 60% of patients with MTS may have a previous history of
FS before developing seizures .
Cendes 2004-2005 ; French et al.,1993 & Tatum 2012

8. Mesial temporal lobe epilepsy- Seizure pattern
• The typical aura is an indescribable rising epigastric sensation,
often described as butterflies and followed by staring,
behavioral arrest and oroalimentary or hand automatisms,
accompanied by autonomic phenomena as pupillary dilatation,
hyperventilation, piloerection, and tachycardia.
• Contralateral dystonic posturing with ipsilateral automatisms
during the seizure are reliable lateralizing signs .
Acharya et al., 1998, Thompson et al., 2000 ; Tatum, 2012.

9. Mesial temporal lobe epilepsy
• Typically, by the end of the first or second decade, patients present with
their first complex partial seizure, although it may be a simple partial or
a generalized seizure.
• Afterwards, some patients remain seizure-free for variable periods that
range from one to two decades, or even longer (honeymoon-period).
Seizures restart as adults .

10. • TLE can be associated with a magnetic resonance imaging
(MRI) lesion or be non-lesional.

11. Lesional TLE
• Hippocampal sclerosis
• Benign tumors – Gangliglioma, DNET.
• Vascular malformations
• Cortical development malformations
• Post traumatic/Post infectious gliosis
Woermann & Vollmar, 2009 & Cendes 2005

12. Etiology -Pathophysiology
• HS is the most common cause of TLE, representing greater
than 80% of cases.
• It is a combination of atrophy and astrogliosis of the
hippocampus, amygdala, uncus, parahipocampal gyrus, and
the entorhinal cortex.
• Selective neuronal loss that affects various sectors to a
different degree.
Tatum 2012- J Clinical neurophysiology

13. HS -Macroscopic
Source: Wiki

14. Etiology -Pathophysiology
• The most vulnerable to damage :
- CA1 (Sommer’s sector) and CA3-CA4 (endfolium)-
- CA2 pyramidal and dentate gyrus granule cells are most seizure
resistant.
• The majority of hippocampal specimens also reveal alterations
within the dentate gyrus, i.e., granule cell dispersion.
Cendes, 2004 & 2005

15. Hippocampal microanatomy
Cresyl-violet and Luxol-Fast-Blue
staining of a postmortem human
hippocampus
• SUB, subiculum
• CA1–CA4, sectors of the Cornu
ammonis
• DG, dentate gyrus
• HF, remnant of hippocampal fissure
• ALV, alveus
• FIM, fimbria.
Blumcke 2013

16. ILAE - HS
Blumcke 2013
0= no obvious neuronal loss or moderate
astrogliosis only.
1=moderate neuronal loss and gliosis
2=severe neuronal loss and gliosis

17. HS-ILAE Type 1
Blumcke et al., 2013
ILAE hippocampal sclerosis type 1
shows pronounced preferential
pyramidal cell loss in both CA4 and
CA1 sectors.
This is the most common type of HS.
• The CA1 segment is most severely affected (with
>80% cell loss;).
• Other segments also show significant neuronal cell
loss , affecting 30–50% of pyramidal neurons in CA2,
30–90% of neurons in CA3, and 40–90% of neurons
in CA4.
• The dentate gyrus (DG) is usually affected by 50–
60% granule cell loss. Note variable cell loss also in
the dentate gyrus.
NeuN immunohistochemistry with
hematoxylin counterstaining using 4-μm–thin
paraffin embedded sections

18. HS-ILAE Type 2
Blumcke 2013
CA1 predominant neuronal cell loss and gliosis.

19. HS –ILAE Type 3
Blumcke 2013
CA4 predominant neuronal cell loss and gliosis

20. HS-ILAE Type 4
Blumcke 2013
No hippocampal sclerosis.

21. Etiology -Pathophysiology
• Granule cell dispersion may be associated with early seizure onset or
status epilepticus at an initial stage of the disease.
• MTS can occur in combination with a second temporal lobe
epileptogenic pathology such as -
- cortical dyslamination (i.e., Focal Cortical Dysplasia type I)
- ectopic white matter neurons
- low-grade glioneuronal tumors.
Blümcke, 2008

22. Etiology -Pathophysiology
• The most common types of extra-hippocampal lesions found in
dual pathology are
• cortical dysgenesis
• gliotic lesions
• Volume loss is present in ipsilateral thalamus, caudate, and
amygdala in mesial TLE, and thalamic cell loss is present in
epilepsy patients.
Cendes et al., 1995 & Spencer, 2002b

23. Importance of HS classification
• HS ILAE type 1 is more often associated with a history of initial
precipitating injuries before age 5 years, with early seizure
onset, and favorable postsurgical seizure control.
• CA1 predominant HS ILAE type 2 and CA4 predominant HS
ILAE type 3 have been studied less systematically so far, but
some reports point to less favorable outcome.
Blümcke I, et al. Epilepsia. 2013.

24. Neocortical Temporal Epilepsy
• NTE has a different clinical profile than mesial epilepsy.
• A history of FS, CNS infection, perinatal complications or head
injury is less common than in patients with MTS.
• Seizures in patients with NTE appear five or ten years later
than in MTS.
Gil-Nagel & Risinger, 1997, O'Brien et al., 1996; Maillard et al., 2004; Kennedy & Schuele, 2012

25. Neocortical Temporal Epilepsy
• Around 60% of seizures are preceded by an aura, such as
auditory phenomena, psychic experiences or déjà vu and
jamais vu, visual distortions, and vertiginous symptoms.
• Motionless staring and unresponsiveness are the first objective
clinical signs, often followed by early contralateral clonic
movements and secondary generalization.

26. Familial Autosomal Dominant Lateral Temporal Lobe Epilepsy
(Autosomal Dominant Focal Epilepsy with Auditory Features)
• Age at onset:Teenage or early adult hood
• Genetics:Autosomal dominant with high(80%) penetrance
• Mutations : LG1(leucine-rich, glioma-inacivated )/Epitempin gene on Chromosome
10 Q
• Clinical sx: Simple focal seizures that are most common consist of simple auditory
hallucinations( ringing, humming, clicking)
• Infrequently progress into CP seizures and GTC.

27. Mesial vs Neocortical
Loddenkemper & Kotagal, 2005; So, 2006; Jan & Girvin, 2008; Noachtar & Peters, 2009; Foldvary-Schaefer & Unnwongse, 2011

28. Mesial vs Neocortical
Loddenkemper & Kotagal, 2005; So, 2006; Jan & Girvin, 2008; Noachtar & Peters, 2009; Foldvary-Schaefer & Unnwongse, 2011

29. Aura
• Auras are usually subjective symptoms with no objective signs.
• This lasts for seconds up to minutes, although they can be seen
in isolation as well.
• Aura itself is a simple partial/focal aware seizure.
Noachtar & Peters, 2009

30. Abdominal aura
• Most common type of autonomic aura.
• An indescribable unpleasant feeling in the peri-umbilical area that
can be static, or ascend to the chest and throat, and can also
descend into the lower abdominal region .
• Often accompanied by nausea.
Thompson et al., 2000; Foldvary-Schaefer & Unnwongse, 2011, Noachtar & Peters, 2009

31. Psychic aura
• Psychic auras consist of fear , anxiety , distortions of
familiarity (déjà vu, jamais vu) and multisensory hallucinations.
• Fear is a limbic aura, considered to be amygdaloid in origin.
(Primary fear)
Noachtar & Peters, 2009, Ebner, 1994, Jan & Girvin, 2008,
Elliott et al., 2009b.

32. Olfactory aura
Noachtar & Peters, 2009; Foldvary-Schaefer & Unnwongse, 2011, Chen et al 2003, Jan&Girvin 2008
• Classically described, as “uncinate fits” are typically unpleasant
smells, often associated with gustatory phenomena.
• Although historically these are typical auras, they are rare
phenomena occurring in only 5% of TLE patients .
• Gustatory auras are even less common than olfactory auras,
and are highly suggestive of a temporal onset .

33. Auditory aura
• Auditory auras usually manifest as auditory hallucination such
as sounds, which are generated by activation of the Heschl’s
gyrus.
• Complex auditory hallucinations, such as hearing voices or
tunes, can also occur.
Noachtar & Peters, 2009; Foldvary-Schaefer & Unnwongse,
2011, Chen et al 2003, Jan&Girvin 2008

34. Other aura
Noachtar & Peters, 2009; Foldvary-Schaefer & Unnwongse, 2011, Chen et al 2003,
Jan&Girvin 2008

35. Automatisms
• Automatisms are repetitive, involuntary, purposeless
movements that are usually inappropriate, but occasionally
may simulate relatively normal events.
• Oro-alimentary automatisms, consisting of lip smacking,
sucking, swallowing or chewing movements, along with
gestural automatisms such as picking or fumbling movements
are suggestive of TLE .
Jan & Girvin, 2008

36. Automatisms
Non lateralizing automatisms
• Oral automatisms- Temporal/Hippocampal
• Dacrystic seizures- Temporal/Hippocampal/Hypothalamic
Speech changes
• Ictal speech arrest-Temporal
• Post ictal dysphasia and aphasia-Temporal-Dominant
• Vocalization- Frontal
Jan & Girvin, 2008

37. Lateralizing signs- Ipsilateral
• Ipsilateral signs
– Unilateral hand automatism- Temporal
– Early nonforced head turn- Temporal
– Postictal nose wiping- Temporal
– Unilateral eye blinking- Temporal
Jan & Girvin, 2008

38. Lateralizing signs- Contralateral
• Contralateral signs
- Unilateral emotional face alteration- Temporal mesial, frontal , Insular
– Unilateral dystonic/ tonic posturing- Temporal/frontal
– Unilateral clonic movements- Frontal
– Figure of 4 sign (70 % temporal and 30 % extratemporal)
– Ictal hemiparesis &postictal hemiparesis-Frontal
– Late contraversive force head turn-Frontal (Broadmann 6 area) or
temporal

39. Work up
• Initial work up :
• EEG & MRI
• Work up for refractory seizures / Presurgical work up:
Phase I –Video EEG
• Imaging- PET, SPECT
• Neuropsych testing
• Wada testing
Phase 2 Invasive monitoring-
• Subdural grids/Depth electrodes

40. Surface EEG and Video EEG
• Surface EEG recordings are less sensitive than invasive studies.
• First EEG is abnormal in only 30-50% of seizure patients
• Serial EEG (by the 3rd) raise the sensitivity to 80-90%
• Sensitivity can be increased by:
– Sleep deprivation- IED (inter ictal epileptiform discharges)
– IED are activated after seizure
– Anterior temporal electrodes, sphenoidal electrodes or closely placed electrodes
– Longer duration of scalp EEG
Noachtar & Rémi, 2009

41. Video EEG
• Video-EEG allows increasing the likelihood of detecting
interictal epileptiform activity, as well as allowing visual
analysis of seizure.

42. Interictal findinings
• Lateralized arrhythmic (irregular) delta activity may be found in
up to 66% of patients with TLE and is highly concordant with
temporal spiking .
• Temporal intermittent rhythmic delta activity (TIRDA) is a more
specific and accurate interictal indicator of TLE .
• TIRDA consists of trains of rhythmic delta activity lasting 4- 20
seconds . It is related with epilepsy in 80% of cases .
Koutroumanidis et al., 2004, Geyer et al., 1999; Jan et al., 2010, Geyer et al., 1999, Javidan, 2012

43. Interictal-TIRDA
Javidan 2012 -Hindwai
Repetitive, rhythmic, saw-toothed or sinusoidal
Predominantly over the anterior temporal region
Short bursts or trains of 3 seconds or more
Temporal Intermittent Rhythmic Delta
Activity (TIRDA) recorded in a patient with
left temporal lobe epilepsy

44. Interictal-Sharp wave
Javidan 2012 –Hindwai, erles et al., 1998; Noachtar & Rémi, 2009).
29-year-old woman with history of complex partial seizures.
Scalp EEG demonstrates sharp waves over F7-T3.
The classic interictal EEG
abnormality of mesial TLE is a
spike or sharp wave, which
usually are electronegative
waves over the anterior
temporal region (F7/F8).
Mid temporal (T3/T4) and
posterior temporal (T5/T6)
spikes or sharp waves are
more likely to originate from
the temporal neo- cortex .
Interictal spikes predict the
epileptogenic focus with a
probability greater than 95% .
Patients with TLE frequently
have interictal epilepti form
discharges independently in
both temporal lobes .

45. Ictal EEG pattern
• The Type I is characterized by rhythmic 5-9 Hz theta activity that slowly evolves
and remains localized to the temporal or sub-temporal regions. It is the most
specific pattern for seizures originating from the hippocampal areas.
• The type II is characterized by rhythmic slow activity (2-5 Hz) with widespread
temporal distribution. It is frequently associated with neocortical seizures.
• The type III is characterized by diffuse ictal EEG changes or attenuation without
clear lateralization. This pattern can be seen in hippocampal and temporal
neocortical seizures
Ebersole & Pacia, 1996

46. Scalp EEG
On the left: A coronal T2-weighted 3T MRI section shows reduced hippocampal volume and increased signal, consistent with left mesial
temporal sclerosis. On the right: scalp EEG recording shows interictal epileptiform activity on the left anterior temporal region
(maximum at F7 electrode).
Abundant spikes over the left temporal region, maximum at F7-T3 with spread to T5 electrode.

47. Scalp EEG
Scalp EEG recording showing lateralized ictal rhythmic 7 Hz activity, maximally at F7
Ref:Lady D. Ladino, Farzad Moien-Afshari and José F. Téllez-Zenteno

48. Intracranial recording
• The main purpose of intracranial recording is to delineate the area
of onset and early propagation of a seizure.
• Main reasons for invasive recordings:
• Seizures lateralized, but not localized
• Discrepancy between electrographic seizure location and the rest
of the data (e.g. location of lesion on imaging)
• seizures localized in eloquent cortical areas
Lady D. Ladino, Farzad Moien-Afshari and José F. Téllez-Zenteno 2014

49. Advantages of intracranial recording
• Better spatial resolution
• Increased sensitivity
• No attenuation from scalp and skull
• Reduced ictal electromyographic artifacts
• Providing the option of cortical stimulation
Lady D. Ladino, Farzad Moien-Afshari and José F. Téllez-Zenteno 2014

50. Intracranial recording
• Ultimately, the localization is achieved by combining the data
from invasive monitoring with a detailed analysis of the clinical
semiology, and the information obtained from the video-EEG
monitoring and other tests such as MRI, SPECT or PET.
Ref:Lady D. Ladino, Farzad Moien-Afshari and José F. Téllez-Zenteno

51. Intracranial recording
• Currently, subdural electrodes are the most common invasive
method used in the United States.
http://www.annalsofian.org/

52. Intracranial recording
• Despite the high spatial resolution provided by the subdural
methodology, relatively deep epileptogenic foci cannot be
sampled.

53. Subdural vs depth electrodes
http://www.annalsofian.org/

54. Depth electrode

55. Depth electrode
• Depth electrodes or stereo-electroencephalography is a safe and
accurate procedure for invasive assessment of the epileptogenic
zone.
• Allows direct electrical recording from deep-seated brain
structures, providing essential information in the most complex
cases of DRE .
• Allows sampling from deep zones such as, amygdala,
hippocampus, entorhinal cortex, and insular cortex .
Cardinale et al., 2012

56. Depth electrodes On the left: at the top
coronal Fluid-attenuated
inversion recovery (FLAIR)
3T MR, at the bottom axial
FLAIR 3T MRI. Both
sequences showing
bilateral implanted depth
electrodes.
On the right: at the top
intracranial EEG recording
showing ictal lateralized
fast activity (12Hz),
maximally at RPH3-4 (Right
Posterior Hippocampus), at
the bottom there is ictal
lateralized fast activity
(16Hz), maximally at LPH3
(Left Posterior
Hippocampus).

57. Depth electrode
Intracranial EEG recording with depth electrodes showed a clear onset over the mesial electrodes in the right temporal region
RHH1-2 (Right hippocampus head) and RHB1-2 (right hippocampus body).

58. MRI
The coronal T2WI and FLAIR images show right-sided mesial temporal sclerosis.
Notice the volume loss, which indicates atrophy and causes secondary enlargement of the temporal horn of
the lateral ventricle.
The high signal in the hippocamous reflects gliosis.
Classical findings:
• Reduced hippocampal volume
:Hippocampal atrophy(95%)
• Increased T2 signal( 85%)
• Abnormal morphology : loss of
internal architecture (interdigitations
of hippocampus)(60-95%)
Lady D. Ladino, Farzad Moien-Afshari and José F. Téllez-Zenteno

59. PET scan - FDG
• The glucose analog FDG is the tracer most widely used. It is an indirect marker of neuronal activity.
• The epileptogenic focus in the interictal phase usually appears as a hypometabolic
area on FDG-PET.
• Hypometabolism is likely due to factors such as neuronal loss and reduction in synaptic density .
• The area of decreased glucose utilization in TLE is typically more extensive than the epileptogenic
zone and may extend into the adjacent inferior frontal or parietal lobe cortex, as well as the
ipsilateral thalamus.
La fougère et al., 2009, Van Paesschen et al., 2007; Wehner & Lüders, 2008; Carne et al., 2007

60. PET
• Thus FDG-PET has lateralizing value rather than localizing
significance in TLE, mainly by confirming hypometabolism in
the area considered for surgical resection .
• As a rule, PET and SPECT scans must be used only as an
adjunct test in surgical planning of patients with epilepsy.
Van Paesschen et al., 2007; Richardson, 2010, Carne et al., 2007

61. PET-Hypometabolism in left temporal lobe
13-year-old boy with partial complex epileptic seizures. (a) Coronal PET image, (b) MRI image. MRI does not show any clear abnormality, while on
the PET image, there is marked hypometabolism in the left temporal pole.
Radiologykey.com

62. SPECT
• Application is based on the assumption that the increased ictal
neuronal activity during epileptic seizures is associated with
increased metabolism and regional cerebral blood flow (rCBF).
• Ictal SPECT has a high sensitivity to localize the epileptic focus.
• It utilizes 99m Tc-hexamethyl- propyleneamine oxime (99m Tc-
HMPAO) or 99m Tc-ethylcysteinate dimer (99m Tc-ECD) to study
cerebral perfusion in the ictal state.
Lee et al., 2011, Van Paesschen et al., 2007, Wehner & Lüders, 2008

63. SPECT
• rCBF changes during seizures may begin with hyperperfusion in the
epileptic zone followed by rapid extension to other regions due to
seizure spread and generalization.
• Thus, a SPECT hyperperfusion pattern often contains both the ictal
onset zone and the propagation pathways.
• It has been estimated that the seizure should last at least ten
seconds after the injection in order to obtain localizing information.
La fougère et al., 2009, Richardson, 2010, Wehner & Lüders, 2008, Newton et al., 1992.

64. SPECT
Interictal technetium-99m ECD brain SPECT scan (top) as compared with an ictal technetium-99m ECD brain SPECT scan .
Substraction images show increased hyperremia in left temporal lobe

65. SISCOM
http://www.synapticom.net/nucmedlab/

66. Language and memory tests
• Wada
• Neuropsych evaluation
• fMRI

67. WADA test
• The intracarotid amobarbital procedure (IAP) was first reported by Wada in 1949
and was used for language lateralization.
• Since the early 60s the Wada test also has been used to predict postoperative
amnesia, memory decline and language disability in the presurgical evaluation of
TLE.
• This test uses the functional inactivation of a single hemisphere by injection of
sodium amobarbital into the ipsilateral internal carotid artery.
• During this temporary deficit, the language and memory abilities of the active
contralateral hemisphere can be assessed in isolation. Both hemispheres are
tested consecutively with about 30 minutes between injections.

68. fMRI
• Presurgical evaluation, to determine the hemispheric dominance for language.
• Numerous studies have demonstrated a very good correlation between fMRI and
the Wada test .
• Advantages over Wada test, which include being a non-invasive risk-free
technique, lower cost, repeatability, and generating continuous measure of
language lateralization.
• The main limitations of the fMRI are the presence of artifacts mainly generated
by movement and patient’s high cooperation demand in order to perform the
tasks
Sabbah et al., 2003, Rabin et al., 2004

69. Neuropsychological (NP) testing
• Mandatory part of presurgical evaluation
• TLE – memory and language
• Dominant TLE – verbal memory deficits
• Non dominant TLE – visuospatial memory deficits
• Memory decline – most common deficit after TLE surgery
• Patients with average or above average memory and language function are
at higher risk for developing postoperative deficits

70. Treatment
• Antiepileptic drugs
• Surgical resection

71. Antiepileptic drugs
• About 60% of patients with TLE respond to AEDs, and 40% have
DRE epilepsy.
• The drug of choice for the first-line monotherapy in TLE is
carbamazepine or oxcarbazepine.
• Other monotherapy options are lamotrigine, levetiracetam,
valproate , Lacosamide and topiramate.
Kwan & Sander, 2004

72. Antiepileptic drugs
• ILAE defines DRE as failure of adequate trials of two tolerated
and appropriately chosen and used AED schedules (whether as
monotherapies or in combination) to achieve sustained seizure
freedom.
Kwan et al., 2010

73. Surgical treatment
• 40 percent of patients with partial epilepsy will eventually
become refractory to medical treatment and could be potential
candidates for epilepsy surgery.
Kwan & Sander, 2004,

74. DRE-epilepsy surgery
• DRE is associated with significant risks for death, physical
injury, cognitive impairment, and psychosocial problems.
• Early referral for epilepsy surgery is advisable in selected cases.

75. Surgical treatment
• The safety and efficacy of surgery for TLE was well established
in a randomized clinical trial by Wiebe .
• In this study, 80 patients with TLE were randomized to receive
medical treatment versus surgical treatment.
Wiebe et al., 2001

76. Surgical treatment
• At the end of the first year of follow-up 58% of patients in the
surgical group were seizure-free compared with only 8% of
those receiving medical treatment (P < 0.0001)
Wiebe S et al. N Engl J Med2001;345:311-318

77. Surgical treatment
• The most common epilepsy surgery procedure is temporal lobe
resection.
• The procedures more frequently practiced are standard
anterior temporal resection and amygdalo- hippocampectomy.
• Several studies report similar success rate with both
techniques achieving seizure freedom between 60 and 70%.
Lutz et al., 2004

78. Surgical treatment
• After left temporal lobectomy:
• 44% of patients exhibit verbal memory decline
• 34% show naming difficulties.
• The most common neurologic complication after resective epilepsy
surgery is a minor visual field deficit (one quadrant or less) seen in
12.9% of patients, and the majority of cases are asymptomatic.
Sherman et al., 2011 & Macrodimitris et al., 2011a, Hader et al., 2013.

79. Surgical treatment
• Téllez-Zenteno et al performed a systematic review evaluating
long-term outcomes in epilepsy surgery.
• On average- Patients with temporal lobe surgery
• 14% achieved long-term AED discontinuation
• 50% achieved monotherapy
• 33% remained on polytherapy.
Téllez-Zenteno et al., 2007

80. Surgical treatment
• Seizure freedom after surgery was associated with lower
mortality.
• Additionally, successful epilepsy surgery can halt or improve
the cognitive decline seen in chronic epilepsy, and that left
temporal resections have a higher risk of additional post-
operative verbal memory impairment.
Téllez-Zenteno et al., 2007

81. VNS
• The vagus nerve stimulator has been approved as adjunctive
therapy for the treatment of adults and adolescents with refractory
epilepsy.
• “VNS is not more effective than AEDs and has a very low chance of
achieving seizure freedom in drug- resistant epilepsy, so it should
NOT be considered before resective surgery, and should be
reserved for patients who are poor candidates or who refuse
surgery.”
Milby et al., 2009; Burakgazi et al., 2011, Miller, Hakimian. Surgical Treatment of Epilepsy. Continuum. 2013 June;19:730-42

82. Radiosurgical Treatment
• A prospective multicenter European study evaluating Gamma Knife(R) surgery for MTS showed
comparable efficacy rates (65%) for seizure reduction by conventional surgery or radiosurgery, after
two years of follow up .
• Benefial effects of radiosurgery are not displayed immediately. Most patients achieve seizure
reduction at 9–12 months and complete cessation of seizures between 18–24 months after
radiosurgical treatment.
• This procedure is an attractive option for TLE treatment because of its low morbidity and mortality,
however prospective trials with larger numbers of patients will be required to establish radiosurgery
as a standard therapy for mesial TLE.
Régis et al., 2004, Yang & Barbaro, 2008

83. Neuropace
• Responsive neurostimulation

84. Thank you