Outcome after resective surgery is presented in two sections: overall and correlative. This latter contrasts the 26 seizure-free (SF) patients with the 27 patients whose disorders remained the same or worsened, similar to the analysis of Bengzon et al. (19).
Overall (70 patients)
Of the 685 patients undergoing focal resection in this interval, 70 (10%) had normal or nonspecific histology. Of these 70 patients, 19 (27%) had normal histology, and 48 (69%) had nonspecific histology (see Methods). Ten of 19 patients with normal histology had standard temporal resections, as did 31 of 48 patients with mild gliosis. Histology was unavailable in three (4%) of patients, but no lesion was seen by the surgeon. Forty-one (59%) were male patients. The ages at operation ranged from 6 to 65 years (mean, 31 years). Age at habitual seizure onset ranged from 1 to 47 years (mean, 13 years) with a duration of illness before resection ranging from 1 to 41 years (mean, 17 years).
A neurologic antecedent of questionable relevance to the seizure disorder occurred in 41 (59%) of 70 patients. Of these 41, 23 (56%) had one or more brief, nonlateralized, febrile seizures; 13 (32%) had mild closed head injuries without aspects prognostic of posttraumatic epilepsy (27). Four (10%) patients had a history of meningitis, and one had birth asphyxia without immediate sequelae.
Neuroimaging was normal in 47 (67%) of the 70 patients and showed mild, nonfocal atrophy in 23 (33%), as interpreted by our epilepsy neuroradiologist (D.H.L.).
Forty-three (61%) of the 70 patients had standard temporal lobectomy only. Other resections were carried out in the following regions: frontal, 16 (23%); temporal neocortex or standard temporal with other resections, seven (10%); occipital, six (9%); and parietal, three (4%). Some resections involved portions of more than one lobe.
A remarkable aspect was polarization of outcome: although seizures stopped in 26 (37%) of 70, of whom 10 are off medication, 27 (39%) obtained no benefit, and six (22%) have more frequent attacks (Table 2). A worthwhile result appears to have occurred in 35 (50%) patients, as seizure incidence diminished >90% in six non-SF patients, and an additional three have only nocturnal generalized attacks (outcomes I + II, Table 2). A mediocre (∼50%) improvement occurred in eight (11%).
Table 2. Outcome: standard temporal and extratemporal resections
|Neocortical and nontemporal||(30)||(4)||(7)||(59)|| |
|Total||26 (37%)||9 (13%)||8 (11%)||27 (39%)||70|
Outcome was assessed for the 43 patients undergoing only a standard temporal lobectomy including its mesial structures and for all others (27 patients) including temporal neocortical resections only, combined temporal and extratemporal resections, and extratemporal resections only. Of the 43 patients undergoing standard temporal lobectomy, 26 (60%) achieved a worthwhile (I + II) outcome, more than the nine (33%) of 27 patients with temporal neocortex or extratemporal resections (p = 0.0486, significant, Fisher's exact test). Eighteen (42%) of the 43 temporal lobectomy patients became SF compared with eight (30%) of 27 with other procedures [p = 0.3244, Fisher's exact test, not significant (NS)].
Follow-up durations between SF and non-SF patients were similar. The number of antiepileptic medications (AEDs) was decreased in 26 (37%) of 70, increased in 15 (21%), and remained the same in 29 (41%).
Seventeen (24%) of 70 patients obtained some type of residual postoperative complication including a superior quadrantopia (nine patients), hemianopia (two patients), subjective decrease in memory (five patients), and mild hemiparesis (one patient). Transient abnormalities were dysphasia (11 patients) and hemiparesis (one patient). Subdural infection with meningitis occurred in one patient. Transient psychiatric disturbances appeared in five patients, principally depression.