Surgical management of epilepsy

Jetté, Nathalie; Reid, Aylin Y.; Wiebe, Samuel

doi:10.1503/cmaj.121291

Cited by 51 publications

(55 citation statements)

References 46 publications

(61 reference statements)

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“…Anterior temporal lobectomy is a well-established treatment for patients with drug-resistant MTLE [24,25,26,27] and results in 60-80% seizure freedom in selected patients [5,28,29], but is associated with adverse effects, such as cognitive impairments and focal neurological deficits [30,31,32,33,34,35,36]. Therefore, the balance of effectiveness and possible complications of open resection needs to be taken into account for patients with MTLE.…”

Section: Discussionmentioning

confidence: 99%

Optic Radiation Tractography and Visual Field Deficits in Laser Interstitial Thermal Therapy for Amygdalohippocampectomy in Patients with Mesial Temporal Lobe Epilepsy

Yin

Thompson

Drees

et al. 2017

Stereotact Funct Neurosurg

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Background/Aims: Laser interstitial thermal therapy (LITT) has become an alternative to open-resective surgery for refractory mesial temporal lobe epilepsy (MTLE). Occurrence of visual field defects (VFDs) following open surgery for MTLE is reported at 52-100%. We examined the rate of VFDs following LITT for amygdalohippocampectomy (AHE) and correlated the occurrence of VFDs with damage to the optic radiations, assessed by diffusion tensor tractography (DTI). Methods: We performed a retrospective analysis of 5 patients who underwent LITT-AHE for medically refractory MTLE. We examined the association between VFDs and optic radiation damage by correlating postprocedural visual field testing with qualitative assessment of optic radiation fiber tracts. Results: Postoperative assessments showed that 4 patients had normal visual field testing, and 1 had a right superior quadrantanopsia (20%). We performed 3-dimensional reconstruction of the optic radiation, laser probe trajectory, and ablation volume. Damage to Meyer's loop was determined consistent with the VFD. Conclusions: Short-term follow-up in our series suggests that laser ablation AHE may be associated with a lower rate of VFD than has been reported for open AHE. Our results suggest that incorporating optic radiation mapping through DTI may preoperatively help to minimize the risk of VFD following laser ablation AHE.

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Section: Discussionmentioning

confidence: 99%

Optic Radiation Tractography and Visual Field Deficits in Laser Interstitial Thermal Therapy for Amygdalohippocampectomy in Patients with Mesial Temporal Lobe Epilepsy

Yin

Thompson

Drees

et al. 2017

Stereotact Funct Neurosurg

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“…Understanding the mechanisms driving seizure outcomes is critical given the current suboptimal seizure‐freedom rates after resective surgery 68. Approaches at improving outcomes should expand beyond improving epilepsy localization to understanding the mechanisms of postoperative epileptogenesis 47, 62.…”

Section: Gaps In Knowledgementioning

confidence: 99%

Not all that glitters is gold: A guide to surgical trials in epilepsy

Jehi

2016

Epilepsia Open

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SummaryEpilepsy surgery is often the only effective treatment in appropriately selected patients with drug‐resistant epilepsy, a disease affecting about 30% of those with epilepsy. We review the evidence supporting the use of epilepsy surgery, with a focus on randomized controlled trials (RCTs). Second, we identify gaps in knowledge about the benefits of epilepsy surgery for certain populations, the challenges of individualizing the choice of surgery, and our lack of understanding of the mechanisms of surgical outcomes. We conducted a search (MEDLINE, Embase, Cochrane, Clinicaltrials.gov) on March 2, 2016, to identify epilepsy surgery RCTs, systematic reviews, or health technology assessments (HTAs). Abstracts were screened to identify resective, palliative (e.g., corpus callosotomy, multiple subpial transection [MST]), ablative (e.g., Laser interstitial thermal therapy [LITT], gamma knife radiosurgery [RS]), and neuromodulation (e.g., cerebellar stimulation [CS], hippocampal stimulation [HS], repetitive transcranial magnetic stimulation [rTMS], responsive neurostimulation [RNS], thalamic stimulation [TS], trigeminal nerve stimulation [TNS], and vagal nerve stimulation [VNS]) RCTs. Study characteristics and outcomes were extracted. Knowledge gaps were identified. Of 1,205 abstracts, 20 RCTs were identified (resective surgery including corpus callosotomy [n = 7], MST [n = 0], RS [n = 1, 3 papers], LITT [n = 0], CS [n = 1], HS [n = 2], RNS [n = 1], rTMS [n = 1], TNS [n = 1], TS [n = 1], and VNS [n = 5]). Most studies targeted patients with temporal lobe epilepsy (TLE) and none examined the effectiveness of resective surgical therapies in patients with extra‐TLE (ETLE) or with specific lesions aside from mesial temporal lobe sclerosis. No pediatric surgical RCTs were identified except for VNS. Few RCTs address the effectiveness of surgery in epilepsy and most are of limited generalizability. Future studies are needed to compare the effectiveness of different surgical strategies, better understand the mechanisms of surgical outcomes, and define the ideal surgical approaches, particularly for patients with high or very low cognitive function, normal imaging, or ETLE.

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“…1 Individuals who do not respond to two appropriately selected antiepileptic drugs have less than a 5% chance of responding to additional medical treatments. 2 In an accompanying review, Jette and colleagues 3 examine evidence showing improved rates of freedom from seizures following surgery in appropriately selected pediatric and adult populations. Surgical treatments for medically refractory epilepsy in children are, however, under used in Canada, with prolonged delays in referral for presurgical evaluation.…”

mentioning

confidence: 99%

“…3 As outlined by Jette and colleagues, 3 there is an added concern about the detrimental effects of recurrent seizures among children, as well as the prolonged use of antiepileptic drugs on the developing brain and, hence, the neurodevelopmental trajectory. Animal models have shown consistently that although the immature brain may be more resistant to cellular loss following prolonged seizure activity than the adult brain, recurrent seizures during brain development result in major changes in synaptic network organization and irreversible alterations in neuronal connectivity.…”

mentioning

confidence: 99%

“…Jette and colleagues review available randomized controlled trials that have validated the benefits of surgical intervention over standard medical therapy for adults with medically intractable temporal lobe epilepsy. 3 Although no trial evidence exists for children, in appropriately selected cohorts with seizure foci arising both within and outside the temporal lobe, the rate of surgical cure may vary from two-thirds to three-quarters. 6 With advanced diagnostic tools, surgical cure may also be achieved for children without an obvious structural lesion (i.e., no lesion visible on magnetic resonance imaging or nonlesional epilepsy) and those with multilobar or widespread epileptic networks.…”

mentioning

confidence: 99%

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