ObjectiveTranssylvian selective amygdalo‐hippocampectomy (tsSAHE) represents a generally recognized surgical procedure for drug‐resistant mesial temporal lobe epilepsy (mTLE). Although postoperative seizure freedom can be achieved in about 70% of tsSAHE, there is a considerable amount of patients with persisting postoperative seizures. This might partly be explained by differing extents of resection of various tsSAHE target volumes. In this study we analyzed the resected proportions of hippocampus, amygdala as well as piriform cortex in regard of postoperative seizure outcome.MethodsBetween 2012 and 2017, 82 of 103 patients with mTLE who underwent tsSAHE at the authors’ institution were included in the analysis. Resected proportions of hippocampus, amygdala and temporal piriform cortex as target structures of tsSAHE were volumetrically assessed and stratified according to favorable (International League Against Epilepsy (ILAE) class 1) and unfavorable (ILAE class 2–6) seizure outcome.ResultsPatients with favorable seizure outcome revealed a significantly larger proportion of resected temporal piriform cortex volumes compared to patients with unfavorable seizure outcome (median resected proportional volumes were 51% (IQR 42–61) versus (vs.) 13 (IQR 11–18), P = 0.0001). Resected proportions of hippocampus and amygdala did not significantly differ for these groups (hippocampus: 81% (IQR 73–88) vs. 80% (IQR 74–92) (P = 0.7); amygdala: 100% (IQR 100–100) vs. 100% (IQR 100–100) (P = 0.7)).InterpretationThese results strongly suggest temporal piriform cortex to constitute a key target resection volume to achieve seizure freedom following tsSAHE.

How brand interaction in pop-up shops influences consumers' perceptions of luxury fashion retailers.

Drug-resistant mesial temporal lobe epilepsy is a devastating disease with seizure onset in the hippocampal formation. A fraction of hippocampi samples from epilepsy-surgical procedures reveals a peculiar histological pattern referred to as ‘gliosis only’ with unresolved pathogenesis and enigmatic sequelae. Here, we hypothesize that ‘gliosis only’ represents a particular syndrome defined by distinct clinical and molecular characteristics. We curated an in-depth multiparameter integration of systematic clinical, neuropsychological as well as neuropathological analysis from a consecutive cohort of 627 patients, who underwent hippocampectomy for drug-resistant temporal lobe epilepsy. All patients underwent either classic anterior temporal lobectomy or selective amygdalohippocampectomy. Based on their neuropathological exam patients with hippocampus sclerosis and ‘gliosis only’ were characterized and compared within the whole-cohort and within a subset of matched-pairs. Integrated transcriptional analysis was performed to address molecular differences between both groups.  ‘Gliosis only’ revealed demographics, clinical and neuropsychological outcome fundamentally different from HS. ‘Gliosis only’ patients have a significantly later seizure onset (16.3 yr. vs. 12.2 yr., p = 0.005) and worse neuropsychological outcome after surgery compared to patients with HS. Epilepsy was less amendable by surgery in ‘gliosis only’ patients resulting in a significantly worse rate of seizure freedom after surgery in this subgroup (43% vs 68%, p = 0.0001, OR = 2.8, CI 1.7-4.7). This finding remained significant after multivariate and matched pairs analysis. The ‘gliosis only’ group demonstrated pronounced astrogliosis and lack of significant neuronal degeneration in contrast to characteristic segmental neuron loss and fibrillary astrogliosis in HS. RNA sequencing of ‘gliosis only’ patients deciphered a distinct transcriptional program that resembles an innate inflammatory response of reactive astrocytes. Our data indicates a new temporal lobe epilepsy syndrome for which we suggest the term ‘Innate inflammatory gliosis only’ (I2GO). Innate inflammatory ‘gliosis only’ is characterized by a diffuse gliosis pattern lacking restricted hippocampal focality and is poorly controllable by surgery. Thus, innate inflammatory ‘gliosis only’ patients need to be clearly identified by presurgical examination paradigms of pharmacoresistant temporal lobe epilepsy patients, surgical treatment of this subgroup should be considered with great precaution. Innate inflammatory ‘gliosis only’ requires innovative pharmacotreatment strategies.

Introduction: Temporal lobe epilepsy (TLE) surgery is still underutilized, especially in the elderly population because of concerns related to postoperative complication rate and cognitive deterioration. The aim of the study was to evaluate surgical data, quality of life and neuropsychological outcome in elderly patients, who underwent resective surgery for drug resistant TLE. Methods and materials: All patients underwent standardized presurgical assessment including clinical, neuroradiological, neuropsychological, and EEG examination. Elderly were considered all patients being 50 years or above (mean 56 yr., range 50−71 yr.). Neuropsychology was assessed before and after surgery, health-related quality of life (HRQOL) only after surgery. Results: A total of 94 consecutive elderly patients were analyzed. Temporo-mesial resections were performed in 85 patients (90 %). Seizure outcome was available in all patients with a mean follow-up of 5.2 years (1.2−19 ± 3.75 years). 57 patients (60.6 %) were completely seizure free (ILAE 1). The overall morbidity was 10 % including 5 surgical complications and 5 permanent neurological deficits. Neuropsychological assessments in 60 patients showed considerable preoperative impairment, losses in different domains in 25-45 % and gains in about 25 % of the patients. Postoperative HRQOL data was available in 75 patients, revealing significant increase of HRQOL in all domains. Complete seizure freedom was the strongest predictor for postoperative HRQOL (p < 0.001). Conclusion: Surgery for drug resistant temporal lobe epilepsy is a feasible option for elderly patients as seizure control rates are comparable to the younger population. The acceptable rate of permanent neurological deficits and relevant improvements in quality of life, despite considerable postoperative cognitive impairment, justify surgical resection in properly selected elderly patients.

OBJECTIVETemporal lobe epilepsy (TLE) is one of the most common forms of epilepsy. In approximately 30% of patients, seizures are refractory to drug treatment. Despite the achievements of modern presurgical evaluation in recent years, the presurgical prediction of seizure outcome remains difficult. The aim of this study was to evaluate the seizure outcome in patients with drug-refractory TLE who underwent resective temporal lobe surgery (rTLS) and to determine features associated with unfavorable postsurgical seizure outcome.METHODSPatients with medically refractory TLE who underwent rTLS between 2012 and 2017 were reviewed from the prospectively collected epilepsy surgery database. A retrospective analysis of clinical, radiological, neuropsychological, histopathological, and perioperative findings of 161 patients was performed. The patients were divided into two groups according to seizure outcome (group I, International League Against Epilepsy [ILAE] class 1; group II, ILAE class ≥ 2). For identification of independent risk factors for unfavorable postoperative seizure outcome (ILAE class ≥ 2), a multivariate logistic regression analysis was performed.RESULTSSeizure freedom (ILAE class 1) was achieved in 121 patients (75.2%). The neuropsychological evaluation demonstrated that losses in cognitive performance were more pronounced in verbal memory after resections in the left temporal lobe and in nonverbal memory after right-sided resections, whereas attention improved after surgery. Overall, postoperative visual field deficits (VFDs) were common and occurred in 51% of patients. There was no statistically significant difference in the incidence of VFD in patients with selective surgical procedures compared to the patients with nonselective procedures. The lack of MRI lesions and placement of depth electrodes were preoperatively identified as predictors for unfavorable seizure outcome.CONCLUSIONSrTLS is an effective treatment method in patients with refractory TLE. However, patients with a lack of MRI lesions and placement of depth electrodes prior to rTLS are at higher risk for an unfavorable postsurgical seizure outcome.