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Epilepsy Board Study > Epilepsy Surgery > Flashcards

Epilepsy Surgery Flashcards

1
Q

Treatment options for medically refractory epilepsy

A
  1. Surgical resection
  2. VNS
  3. Multiple subpial transections
  4. DBS
  5. OThers: DBS, transgeminal nerve stimulation, external VNS, transcranial direct current stimulation, ketogenic diet
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2
Q

Best predictor of postoperative adequacy

A

Preoperative cognitive and psychosocial status

-Lower the preoperative cognitive and psychosocial status, the lower the risk of further decline

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3
Q

Intracarotid Amobarbital Procedure (Wada)

A

Helps lateralize language dominance and memory function

Can lateralize seizure onset (side with poor memory likely seizure onset)

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4
Q

Surgical Outcomes

A

At 1 year, patient seizure free 58% compared to 8% on medication

People with surgery
Had less CPS and better quality of life
10% had adverse side effects - language and memory related problems

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5
Q

Early Randomized Surgical Epilepsy Trial (ERSET)

A

Outcomes:
Seizure freedom 11/15 pts in surgical 0/23 in medical group
QOL better in surgical group
Memory decline in 36% of pts after surgery
Adverse events: stroke - surgical case. 3 with status in medical group

Resective surgery +ASM in patients with new refractory MTLE results in lower probability of seizures in second year

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6
Q

Surgical Methods

A 
Temporal lobe surgery
Lobectomy
Resection of epileptogenic zone
Lesionectomy
Corpus Callosotomy
Hemispherectomy
Multiple subpial transection
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7
Q

Different Methods for temporal lobectomy

A

Standard (en bloc) anterior temporal lobectomy (ATL) - 3-6 cm of anterior temporal neocortex + 1-3 cm of MTS (amygdala + hippocampus)

Modified + limited neocortical resection = 3.5cm from temporal pole sparing superior temporal gyrus (avoid language deficits)

Selective amygdalohippocampectomy

Stereotactic radiosurgery

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8
Q

Standard Amygdalohippocampectomy

A

Attempts to preserve lateral temporal cortex out of concern for language deficits

  • Resect up to 4-4.5 cm on dominant
  • Resect u up to 6-6.5cm on nondominant
  • Preserves the neocortical areas
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9
Q

Outcomes following Temporal lobe surgery

A

seizure free rates:
At 12 months - 82%
At 24 months 76%
At 63 months - 64%

Complete or better seizure outcome was associated with significantly better QOL
Risk factor for seizure recurrence was reduction in ASM

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10
Q

Standard Anterior Temporal Lobectomy OUtcomes

A

Seizure freedom 89%
Engel Class I or II - 94%

*Highest concordance was with video EEG > PET> MRI > Wada > SPECT/Neuropsych

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11
Q

Inferior Temporal approach to Standard Anterior Temporal Lobectomy

A

safe and effective with low morbidity and mortality.

Complications: delayed SDH, wound infections, delayed ICH, small lacunar stroke, one transient frontalis nerve palsy

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12
Q

Selective Amygdalohippocampectomy (SAH)

A

Aim: Minimize neurocognitive side effects of temporal lobectomy
Result: Some improved, some no clear benefit or event significant verbal memory deficits (in dominant SAH)

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13
Q

Risk of Neurocognitive Deficits and Risk factors following ATL

A

Larger temporal lobe resection associated with better seizure control, but also high risk of cognitive outcome

> 2 cm for mesial
4cm for neocortical

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14
Q

Standard vs Selective Temporal Lobe Surgery

A

ATL is more likely to achieve Engel Class I outcome compared to SAH
Thus, standard ATL confers better chance of seizure freedom

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15
Q

Comparison of right vs left temporal lobectomy

A

Post-operative after Left temporal lobectomy:

  • Verbal memory decline
  • Performance intellegence decline

Post-operative after RTL:
-visuospatial memory outcome

More resection is associated with worse functioning

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16
Q

Outcome following nonlesional partial epilepsy surgery

A 
Engel Class I 
81% at 6mo
78% at 1 year 
76% at 2 years
74% at 5 years
72% at 10 years
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17
Q

Positive Predictors for outcome for nonlesional epilepsy surgery

A

Seizure control at 1 year –> 92% prob of remission at 10 years

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18
Q

Negative Predictors for nonlesional epilepsy surgery

A

Extratemporal seizure focus
Previous surgery
Male gender
Normal tissue pathology

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19
Q

Outcome following ATL in Nonlesional TLE

A

Complete seizure freedom rates:
1 year 76%
2 years 66%
7 years 47%

*Memory decline reported with dominant hippocampus resection

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20
Q

Negative predictors (risk factors) for outcome of nonlesional TLE surgery

A

Higher baseline seizure frequency

Preoperative GTCs

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21
Q

Outcome following Frontal Lobe Surgery

A

Patients with identifiable lesion more likely to achieve seizure freedom than those with poorly localized lesion

Engel class I outcome 45.1%

22
Q

Predictors for long term seizure freedom in FLE

A

Lesional origin
Abnormal MRI
Localized frontal resection (vs extensive lobectomy)
Earlier seizure resection in FLE

23
Q

Risk factors for lack of seizure freedom in FLE

A

Left frontal lobe epilepsy surgery
Dominant hemisphere
Patients without aura
Interictal epileptiform discharges in scalp
Intracranial EEG widespread >2 cm) in contracst to focal seizure onset
Shorter latency to onset of seizure spread
Ictal involvement beyond frontal lobe

*Lack of seizure freedom is likely because of widespread epileptogenicity

24
Q

Supplementary Motor Area Seizures
Semiology
EEG

A

Tonic posturing of extremities, usually bilateral
“Fencer posturing”
Usually retained awareness
Usually epileptogenic zone is outside of SMA with rapid spread to SMA

EEG: ictal, interictal EEG often unrevealing.

25
SMA Surgery approach
If seizure outside of SMA -> resection of epileptogenic zone, leaving SMA intact Resect SMA while sparing primary motor cortex --> can result in >90% seizure reduction
26
SMA resection side effects
Transient paresis or severe defciit without permanent loss of motor or speech functions (usually 24hrs) Favorable outcome is common
27
Multiple subpial transection (MST) | Used in:
Introduced to spare eloquent cortex in patients in where epileptogenic zone lies in eloquent cortex Also used in LKS
28
MST outcomes
MST + resection = MST alone | >95% seizure reduction compared in >95% in MST alone
29
Overall Seizure-Free Outcome
``` Temporal Lobectomy 55-80% Frontal lobe resection 5-18% Frontal Lobectomy 23-68% Parietal Lobe resections 45% Occipital Resections 44-88% Hemispherictomy 60% ```
30
Long term outcome (>5 years) Seizure Free
``` Temporal Lobe resections 66% Occipital and parietal resections 46% Frontal lobe resections 27% Multiple subpial transections 16% Callosotomy 35% (from most disabling seizures) ```
31
Failed Epilepsy Surgery and Reoperation
Seizure freedom reported 36.6% | Complications rate at 13.5%
32
Parietal Lobe epilepsy | Semiology
Auras (94%) -somatosensory (pain, dysesthesias), vertigo, aphasia, disturbances with ones own body image Ictal propagation to SMA -> hypermotor manifestations Ictal propagation to temporo-limbic regions -> complex visual or auditory hallucinations and automatism Given propagation, semiology is less of value
33
Parietal lobe seizures EEG
Variable scatter of interictal discharges Less localizing ictal EEG HFO helpful in seizure
34
Parietal lobe surgery SE and outcome
Postoperative sensory deficits - temporary partial hemisensory or Gerstmann syndrome when corticetomy involves post-central gyrus Outcome: complete or nearly seizure freedom 65-67.5% favorable outcome
35
Parietal lobe epilepsy pathologies
low grade tumors Cortical dysplasia Gliotic scars Cavernous vascular malformations
36
Occipital lobe epilepsy | Seizure semiology
Auras reported in 88% of patients - Elementary visual hallucinations, ictal amaurosis, eyemovement sensations, early forced eye blinking or eye lid flutter, contralateral visual field deficits - Often head, eye deviation (often contralat) - LOC - Various automatisms, fumbling, asymmetric tonic or focal clonic motor Medial/lobar lesions - more likely to cause VF defects
37
Occipital lobe EEG
scalp EEG rarely localizing | Intracranial EEG correctly localizes seizure origin
38
Occipital lobe epilepsy resection outcome
46-88% seizure freedome Most common pathologies - dysplasia, tumors, gliosis Following resection - ~50% will not experience any new VF deficits
39
Insular-Opercular Seizures
Nocturnal-Complex motor seizures Auras include: Vicerosensitive or somatosensory symptoms. Ictal Semiology: asymmetric tonic-dystonic posturing, hyperkinetic autosmatisms (bimanual, bipedal activity and ballistic movements)
40
Insular-Opercular Seizures on EEG
Simultaneous insular and opercular ictal discharges are present Complex motor manifestation --> when spreads to frontomesial regions (cingulum, superior frontal gyrus, SMA) and/or mesial/neocortical temporal lobe structures
41
Outcome of insular-opercular Surgical outcomes
Insular opercular cortical resections have favorable outcome | Usually pathology: dysplasia
42
Epilepsy Surgery in Children
49% seizure freedom 13% experience >75% seizure reduction Cognitive outcomes 76% followed their expected cognitive trajectory
43
HFO and Epilepsy in Children
Intracranial EEG demonstrated high prevalence of ictal HFOs zones in 93% of patients Complete resection of ictal HFO is highly associated with favorable surgical outcome -Complete seizure freedom 82% in complete HFO resection vs 21% after incomplete resection
44
Complications of Depth Electrodes
Asymptomatic subdural bleeding gliosis, degeneration, microabscesses along electrode tract 0.5-5%
45
Complications of Sub dural electrodes
``` Infection Transient neurologic deficits Epidural hematoma Increased intracranial pressure Infarction Death 0.5% CSF leak ``` More likely to have complications if >60 electrodes and if grids left in >10 days Risks: Older patients, left sided placement, additonal burr holes
46
Engel Class Definitions
Class I = seizure free with no aura beginning one month after surgery Class II = patients with auras only Class III = patient with 1-3 seizures per year Class 4 = patients with seizures ranging from 4/year to 50% decreased days with seizures Class 5= Patients with 50% reduction to 100% increase in days with seizures. Class 6 = patients with > 100% increase Classes 3-6 include patients with or without auras
47
Memory and Post operative Epilepsy Surgery | Can be worse when
1. Dominant hemisphere temporal lobe resection 2. MRI does not show excluse unilateral MTS 3. Preoperative immediate and delayed recall memory is intact Specifically decline in object naming
48
Memory in post-operative epilepsy surgery can improve
Nondominant resection is performed
49
Adverse effects of TLE surgery
``` Quadrantanopsia/Visual field deficits --> 2-4% with hemianopsia Memory problems Hemiparesis (2.4%) Anterior choroidal artery or other occlusions/strokes Cerebellar hemorrages Infection Epidural Hematomia Transient 3rd ner ve palsy 20% transient anomia 1-3% dysphagia 2-20% transient psychosis or depression ``` Death is 0.24% of pateints
50
Acute Disconnection Syndrome
Akinetic mutism Incontinence Apraxia Alien hand syndrome This is though to be due when entire CC sectioned initally --> most like to do anterior 2/3 section first
51
MEG and TLE | Where are the dipoles?
Mesial = anterior temporal horizontal anterior posterior dipoles Anterior temporal = vertical dipoles Lateral = posterior temporal vertical dipoles

Epilepsy Board Study (8 decks)

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