The Timing of Surgical Intervention for Mesial Temporal Lobe Epilepsy

Engel, Jerome

doi:10.1001/archneur.56.11.1338

Cited by 79 publications

(56 citation statements)

References 23 publications

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“…This practice parameter provides no evidence for guidelines on when to abandon pharmacotherapy and consider surgical intervention. 8,68,69 The literature suggests that the prognosis for complete freedom from disabling seizures following failure of two antiepileptic drugs diminishes rapidly as more antiepileptic drugs are found to be ineffective, that very few patients become free of disabling seizures when it is considered necessary to use two antiepileptic drugs, and that virtually none become free of disabling seizures when three drugs are necessary. 2 Contrasting these data with the consistently excellent prognosis for becoming free of disabling seizures with surgical intervention and the increasing evidence that continuation of disabling seizures over many years, particularly through adolescence and young adulthood, can result in irreversible psychosocial consequences raises consideration of surgical intervention for complex partial seizures after failure of two or three first-line antiepileptic drugs.…”

Section: Discussionmentioning

confidence: 99%

Practice parameter: Temporal lobe and localized neocortical resections for epilepsy

Engel

Wiebe²,

French³

et al. 2003

Neurology

794

291

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Abstract-Objectives/Methods: To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures by systematic review and analysis of the literature since 1990. Results: One intention-to-treat Class I randomized, controlled trial of surgery for mesial temporal lobe epilepsy found that 58% of patients randomized to be evaluated for surgical therapy (64% of those who received surgery) were free of disabling seizures and 10 to 15% were unimproved at the end of 1 year, compared with 8% free of disabling seizures in the group randomized to continued medical therapy. There was a significant improvement in quantitative quality-of-life scores and a trend toward better social function at the end of 1 year for patients in the surgical group, no surgical mortality, and infrequent morbidity. Twenty-four Class IV series of temporal lobe resections yielded essentially identical results. There are similar Class IV results for localized neocortical resections; no Class I or II studies are available. Conclusions: A single Class I study and 24 Class IV studies indicate that the benefits of anteromesial temporal lobe resection for disabling complex partial seizures is greater than continued treatment with antiepileptic drugs, and the risks are at least comparable. For patients who are compromised by such seizures, referral to an epilepsy surgery center should be strongly considered. Further studies are needed to determine if neocortical seizures benefit from surgery, and whether early surgical intervention should be the treatment of choice for certain surgically remediable epileptic syndromes.

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Section: Discussionmentioning

confidence: 99%

Practice parameter: Temporal lobe and localized neocortical resections for epilepsy

Engel

Wiebe²,

French³

et al. 2003

Neurology

794

291

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“…MTLE commonly starts during the first decade of life, when it is often amenable to control with AEDs. However, by adolescence or early adulthood, it frequently becomes refractory (21,22). Most of the patients with MTLE have histopathologic and MRI evidence of neuropathologic damage (23,24).…”

Section: Is Refractory Epilepsy Progressive?mentioning

confidence: 99%

“…Advocates for very early surgery point out that there is relatively low surgical morbidity, that outcome is better when the surgery is done as early as possible, and that devastating consequences of some refractory epilepsy syndromes in children may be avoided with early surgery (21,22,73,(81)(82)(83). However, the inherent risks associated with surgery mandate that medical therapy be tried first for a period of time.…”

Section: Can "Progressive Epilepsy" Be Halted?mentioning

confidence: 99%

Is Refractory Epilepsy Preventable?

et al. 2002

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Summary: About a third of the patients diagnosed with epilepsy will not be fully controlled with antiepileptic drugs (AEDs), and many of them will have frequent and disabling seizures. These patients will undergo multiple drug trials, most often without complete seizure remission. Moreover, refractory epilepsy is associated with increased morbidity (from seizures and medications), social isolation, unemployment, and overall reduced quality of life. There is evidence that refractory epilepsy can be a progressive disorder, which, if controlled early, might never develop into a full syndrome with all of its associated sequelae. The difficulty lies in identifying at an early stage patients who are likely to progress to intractability. No currently known markers enable clinicians to make this identification with confidence. Advances in pharmacogenomics and our understanding of pharmacologic responsiveness in epilepsy may change this situation. Even now, we are able to identify many patients with a poor prognosis earlier than before, particularly in the pediatric population, in which syndromic classification may provide an approach to predict intractability. The early initiation of aggressive therapy may improve outcome and overall quality of life.

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“…Temporal lobe epilepsy (TLE) is one of the most prevalent neurodegenerative diseases, and seizures in a significant fraction of people with TLE are resistant to antiepileptic drugs (Engel, 1999). Because of the involvement of the hippocampus in the generation and maintenance of seizures in TLE, the conventional treatment of patients with medically intractable TLE has been neurosurgical excision of the hippocampus or both hippocampus and amygdala.…”

Section: Introductionmentioning

confidence: 99%

Restoration of calbindin after fetal hippocampal CA3 cell grafting into the injured hippocampus in a rat model of temporal lobe epilepsy

Shetty

Hattiangady

2007

Hippocampus

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Degeneration of the CA3 pyramidal and dentate hilar neurons in the adult rat hippocampus after an intracerebroventricular kainic acid (KA) administration, a model of temporal lobe epilepsy, leads to permanent loss of the calcium binding protein calbindin in major fractions of dentate granule cells and CA1 pyramidal neurons. We hypothesize that the enduring loss of calbindin in the dentate gyrus and the CA1 subfield after CA3-lesion is due to disruption of the hippocampal circuitry leading to hyperexcitability in these regions; therefore, specific cell grafts that are capable of both reconstructing the disrupted circuitry and suppressing hyper-excitability in the injured hippocampus can restore calbindin. We compared the effects of fetal CA3 or CA1 cell grafting into the injured CA3 region of adult rats at 45 days after KA-induced injury on the hippocampal calbindin. The calbindin immunoreactivity in the dentate granule cells and the CA1 pyramidal neurons of grafted animals was evaluated at 6 months after injury (i.e. at 4.5 months post-grafting). Compared with the intact hippocampus, the calbindin in "lesion-only" hippocampus was dramatically reduced at 6 months post-lesion. However, calbindin expression was restored in the lesioned hippocampus receiving CA3 cell grafts. In contrast, in the lesioned hippocampus receiving CA1 cell grafts, calbindin expression remained less than the intact hippocampus. Thus, specific cell grafting restores the injury-induced loss of calbindin in the adult hippocampus, likely via restitution of the disrupted circuitry. Since loss of calbindin after hippocampal injury is linked to hyperexcitability, re-expression of calbindin in both dentate gyrus and CA1 subfield following CA3 cell grafting may suggest that specific cell grafting is efficacious for ameliorating injury-induced hyperexcitability in the adult hippocampus. However, electrophysiological studies of KA-lesioned hippocampus receiving CA3 cell grafts are required in future to validate this possibility.

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The Timing of Surgical Intervention for Mesial Temporal Lobe Epilepsy

Cited by 79 publications

References 23 publications

Practice parameter: Temporal lobe and localized neocortical resections for epilepsy

Practice parameter: Temporal lobe and localized neocortical resections for epilepsy

Is Refractory Epilepsy Preventable?

Restoration of calbindin after fetal hippocampal CA3 cell grafting into the injured hippocampus in a rat model of temporal lobe epilepsy

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