Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Surgical Methods

A 
Temporal lobe surgery
Lobectomy
Resection of epileptogenic zone
Lesionectomy
Corpus Callosotomy
Hemispherectomy
Multiple subpial transection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Positive Predictors for outcome for nonlesional epilepsy surgery

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Negative Predictors for nonlesional epilepsy surgery

A

Extratemporal seizure focus
Previous surgery
Male gender
Normal tissue pathology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

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

A

Higher baseline seizure frequency

Preoperative GTCs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
Q

SMA Surgery approach

A

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
Q

SMA resection side effects

A

Transient paresis or severe defciit without permanent loss of motor or speech functions (usually 24hrs)
Favorable outcome is common

27
Q

Multiple subpial transection (MST)

Used in:

A

Introduced to spare eloquent cortex in patients in where epileptogenic zone lies in eloquent cortex
Also used in LKS

28
Q

MST outcomes

A

MST + resection = MST alone

>95% seizure reduction compared in >95% in MST alone

29
Q

Overall Seizure-Free Outcome

A 
Temporal Lobectomy 55-80%
Frontal lobe resection 5-18%
Frontal Lobectomy 23-68%
Parietal Lobe resections 45%
Occipital Resections 44-88%
Hemispherictomy 60%
30
Q

Long term outcome (>5 years) Seizure Free

A 
Temporal Lobe resections 66%
Occipital and parietal resections 46%
Frontal lobe resections 27%
Multiple subpial transections 16%
Callosotomy 35% (from most disabling seizures)
31
Q

Failed Epilepsy Surgery and Reoperation

A

Seizure freedom reported 36.6%

Complications rate at 13.5%

32
Q

Parietal Lobe epilepsy

Semiology

A

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
Q

Parietal lobe seizures EEG

A

Variable scatter of interictal discharges
Less localizing ictal EEG
HFO helpful in seizure

34
Q

Parietal lobe surgery SE and outcome

A

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
Q

Parietal lobe epilepsy pathologies

A

low grade tumors
Cortical dysplasia
Gliotic scars
Cavernous vascular malformations

36
Q

Occipital lobe epilepsy

Seizure semiology

A

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
Q

Occipital lobe EEG

A

scalp EEG rarely localizing

Intracranial EEG correctly localizes seizure origin

38
Q

Occipital lobe epilepsy resection outcome

A

46-88% seizure freedome
Most common pathologies - dysplasia, tumors, gliosis

Following resection - ~50% will not experience any new VF deficits

39
Q

Insular-Opercular Seizures

A

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
Q

Insular-Opercular Seizures on EEG

A

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
Q

Outcome of insular-opercular Surgical outcomes

A

Insular opercular cortical resections have favorable outcome

Usually pathology: dysplasia

42
Q

Epilepsy Surgery in Children

A

49% seizure freedom
13% experience >75% seizure reduction
Cognitive outcomes 76% followed their expected cognitive trajectory

43
Q

HFO and Epilepsy in Children

A

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
Q

Complications of Depth Electrodes

A

Asymptomatic subdural bleeding gliosis, degeneration, microabscesses along electrode tract

0.5-5%

45
Q

Complications of Sub dural electrodes

A 
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
Q

Engel Class Definitions

A

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
Q

Memory and Post operative Epilepsy Surgery

Can be worse when

A
  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
Q

Memory in post-operative epilepsy surgery can improve

A

Nondominant resection is performed

49
Q

Adverse effects of TLE surgery

A 
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
Q

Acute Disconnection Syndrome

A

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
Q

MEG and TLE

Where are the dipoles?

A

Mesial = anterior temporal horizontal anterior posterior dipoles
Anterior temporal = vertical dipoles
Lateral = posterior temporal vertical dipoles

Epilepsy Board Study (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions