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 ...
Patient JA (cont)
PMH/PSH: C-section 2004
Allergies: phenytoin
Outpatient meds: topiramate 200mg BID, levetiracetam 1000mg...
Pre-op MRI: Axial
T2
• T2 hyperintensity of right inferior and middle temporal gyri,
correlated well with epileptiform dis...
Pre-op MRI: Coronal
FLAIR
• Hyperintensity on FLAIR of right inferior temporal lobe
• Non-enhancing right pontine lesion
T...
Operative plan
1. 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 m...
2a. Initial resection of epidermoid
• Approach through
medial aspect of
temporal lobe
• Gross: encountered
pearly white ma...
2b. Dissection to anterior pons
• Approach through
medial aspect of
temporal lobe
• Gross: encountered
pearly white mass
•...
2c. Resection of tumor off basilar artery
• Approach through
medial aspect of
temporal lobe
• Gross: encountered
pearly wh...
Post-operative course
• Maintained on home doses of topiramate and levetiracetam
• Interval development of superior quadra...
Temporal lobe epilepsy
1. Background
2. Choosing a surgical approach
Background: Temporal lobe epilepsy
• 20-40% of epilepsy patients have medically refractory epilepsy
(400,000 patients in t...
Background: Surgery for temporal lobe epilepsy
Wiebe et al. NEJM 2001.
- 80 patients randomized
- median of 5 seizures/mon...
Choosing the surgical approach
Outcomes:
Seizure frequency
Neuropsychological outcomes
Approaches:
Anterior temporal lobec...
Three RCTs of surgical approaches:
1. ATL with partial or full hippocampectomy
Wyler et al. Neurosurgery 1995.
Patients: 7...
Three RCTs of surgical approaches:
2. Left ATL +/- sparing of superior temporal gyrus
Hermann et al. Epilepsia 1999.
Patie...
Three RCTs of surgical approaches:
3. Transsylvian vs transcortical approach for SAH
Lutz et al. Epilepsia 2004.
Patients:...
Three RCTs of surgical approaches
Wyler Neurosurgery 70 ATL + full or 69% vs 38% seizure-free at 1 yr
1995 partial hippoca...
Thank you
Pre-operative planning
Mesial temporal lobe epilepsy (MTLE)
Up To Date 2010.
Berg. Curr Op Neurol 2008.
Bender. J Neurosur...
“Quest for optimal resection”
Schramm. Epilepsia 2008.
• Controversial
• Few randomized trials
• Variety of methods
Pre-op EEG/MEG
• Left-dominant language center
• Right >> left temporal interictal
epileptiform discharges
• Discharges co...
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Venteicher_Stanford_MGH_No_Movies_072010.pptx - Slide 1

  1. 1. Patient JA: Surgery for temporal lobe epilepsy Andrew Venteicher Visiting sub-intern Stanford University July 2010
  2. 2. 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.
  3. 3. 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)
  4. 4. 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 resected epidermoid of right cerebellopontine angle, relative to MRIs at outside hospital
  5. 5. Pre-op MRI: Coronal FLAIR • Hyperintensity on FLAIR of right inferior temporal lobe • Non-enhancing right pontine lesion T1 post-gad
  6. 6. Operative plan 1. Resection for epileptic focus: Right anterior temporal lobectomy 2. Microscopic dissection of epidermoid
  7. 7. 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 • Interoperative corticography: eight-lead electrode recorded frequent spikes from anterior hippocampus • Anterior hippocampus and amygdala resected • Entered medial pia to access ambient cistern Netter Dr. Nahed/Dr. Eskandar
  8. 8. 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
  9. 9. 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
  10. 10. 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 PA P Dr. Nahed/Dr. Eskandar
  11. 11. Post-operative course • Maintained on home doses of topiramate and levetiracetam • Interval development of superior quadrantanopsia Pre-op Post-op
  12. 12. Temporal lobe epilepsy 1. Background 2. Choosing a surgical approach
  13. 13. Background: Temporal lobe epilepsy • 20-40% of epilepsy patients have medically refractory epilepsy (400,000 patients in the U.S.) • Etiologies: 1. Mesial temporal sclerosis 2. Infections: Systemic, CNS 3. Vascular: AVMs, cavernomas 4. Neoplasia 5. Congenital: cortical dysplasias 6. Traumatic: TBI, post-operative 7. 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.
  14. 14. Background: Surgery for temporal lobe epilepsy Wiebe et al. NEJM 2001. - 80 patients randomized - median of 5 seizures/month - complications: 55% surgical group developed VF defect (rare memory deficit, infarct, infection)
  15. 15. 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.
  16. 16. Three RCTs of surgical approaches: 1. ATL with partial or full hippocampectomy Wyler et al. Neurosurgery 1995. 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
  17. 17. Three RCTs of surgical approaches: 2. Left ATL +/- sparing of superior temporal gyrus Hermann et al. Epilepsia 1999. 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
  18. 18. Three RCTs of surgical approaches: 3. Transsylvian vs transcortical approach for SAH Lutz et al. Epilepsia 2004. Patients: 80. Subjects: diagnosis of hippocampal sclerosis, age > 16, IQ > 69, not left-handed Operation: transsylvian – pterional crani 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
  19. 19. Three RCTs of surgical approaches Wyler Neurosurgery 70 ATL + full or 69% vs 38% seizure-free at 1 yr 1995 partial hippocampect. No difference in memory First author Journal / Year Pts Operation Outcomes Hermann Epilepsia 30 Left ATL 60% vs 55% seizure-free (N.S.) 1999 + / - STG resection No change in naming Lutz Epilepsia 80 transcortical vs 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
  20. 20. Thank you
  21. 21. Pre-operative planning Mesial temporal lobe epilepsy (MTLE) Up To Date 2010. Berg. Curr Op Neurol 2008. Bender. J Neurosurg 2009. • 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
  22. 22. “Quest for optimal resection” Schramm. Epilepsia 2008. • Controversial • Few randomized trials • Variety of methods
  23. 23. 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 Neurosurg 1999.

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