Predictors of Epileptic Seizures and Ability to Work in Supratentorial Cavernous Angioma Located Within Eloquent Brain Areas

Abstract

BACKGROUND The postoperative outcomes and the predictors of seizure control are poorly studied for supratentorial cavernous angiomas (CA) within or close to the eloquent brain area. OBJECTIVE To assess the predictors of preoperative seizure control, postoperative seizure control, and postoperative ability to work, and the safety of the surgery. METHODS Multicenter international retrospective cohort analysis of adult patients benefitting from a functional-based surgical resection with intraoperative functional brain mapping for a supratentorial CA within or close to eloquent brain areas. RESULTS A total of 109 patients (66.1% women; mean age 38.4 ± 12.5 yr), were studied. Age >38 yr (odds ratio [OR], 7.33; 95% confidence interval [CI], 1.53-35.19; P = .013) and time to surgery > 12 mo (OR, 18.21; 95% CI, 1.11-296.55; P = .042) are independent predictors of uncontrolled seizures at the time of surgery. Focal deficit (OR, 10.25; 95% CI, 3.16-33.28; P < .001) is an independent predictor of inability to work at the time of surgery. History of epileptic seizures at the time of surgery (OR, 7.61; 95% CI, 1.67-85.42; P = .003) and partial resection of the CA and/or of the hemosiderin rim (OR, 12.02; 95% CI, 3.01-48.13; P < .001) are independent predictors of uncontrolled seizures postoperatively. Inability to work at the time of surgery (OR, 19.54; 95% CI, 1.90-425.48; P = .050), Karnofsky Performance Status ≤ 70 (OR, 51.20; 95% CI, 1.20-2175.37; P = .039), uncontrolled seizures postoperatively (OR, 105.33; 95% CI, 4.32-2566.27; P = .004), and worsening of cognitive functions postoperatively (OR, 13.71; 95% CI, 1.06-176.66; P = .045) are independent predictors of inability to work postoperatively. CONCLUSION The functional-based resection using intraoperative functional brain mapping allows safe resection of CA and the peripheral hemosiderin rim located within or close to eloquent brain areas.

Surgical resection of cavernous angioma located within eloquent brain areas: International survey of the practical management among 19 specialized centers

“…However, in the subgroup of asymptomatic, incidental CA, the surgical decision has to be carefully weighed, balancing the risks (bleeding, seizure, surgical risks) together with the patient's wishes and expectations. Aiming to reduce the surgical risks, intra-operative functional brain mapping with direct electrical stimulation under awake conditions is increasingly proposed for CAs [8,10,11,21]. Given the fact that the awake brain mapping can be easily associated with the other technological resources and surgical tools, including intra-operative MRI, the combination of these approaches seems promising [22].…”

“…Although recommendations for management of CA-related epilepsy exist [3], the pre-operative evaluation is not standardized in the context of patients with a CA located within eloquent brain regions and requiring surgical resection [8][9][10]. The pre-operative investigation of CA-related epilepsy is very varied, with no cross-center standardization.…”

“…The pre-operative investigation of CA-related epilepsy is very varied, with no cross-center standardization. Investigations include electroencephalography, dedicated visits by an epileptologist, positron emission tomography scanner, single-photon emission computed tomography, and stereo-electroencephalography [10]. Similarly, there is a variety of different intra-operative tools and techniques used by different centers, including intra-operative imaging (ultrasonography, MRI-based neuronavigation, MRI), intra-operative electrophysiological neuromonitoring (electrocorticography, motor evoked potentials, somatosensory evoked potentials), and intra-operative functional brain mapping at the cortical and subcortical levels using direct intra-operative electrostimulations under awake conditions [8,[11][12][13].…”

Intraoperative brain mapping during awake surgery in symptomatic supratentorial cavernomas

“…Complete resection has been probed to prevent rebleeding (and associated neurological morbidity) and control intractable epileptic seizures. 21 However, in the subset of symptomatic patients harbouring deep-located SCA or SCA located near so-called "eloquent areas", attempting complete resection surgery may cause severe postoperative disability that may permanently affect quality of life and clinical outcome, due to neurological and neuropsychological impairment. The above-mentioned surgical risk implies that surgical attempt to remove SCA located within or near a suspected eloquent area is not as frequent as expected, 19 and conservative management is frequently favoured to avoid surgical complications.…”

Cavernoma-related epilepsy in cavernous malformations located within the temporal lobe: surgical management and seizure outcome

“…However, certain occupations of affected patients do not allow long-term antiepileptic medication or increased risk of seizure (such as professional drivers, construction workers, etc.). 15,22 Therefore, the indication for surgical treatment in CCM-related sporadic seizures might be based on neurovascular as well as epileptological rationales. This circumstance highlights the necessity of close interdisciplinary consultation for patients with CCM-related sporadic epilepsy.…”