Article

Predictive model for refractoriness in Temporal Lobe Epilepsy based on clinical and diagnostic test data.

Serrano-Castro PJ, Payan-Ortiz M, Quiroga-Subirana P, Fernandez-Perez J, Parron-Carreño T

Epilepsy Research (impact factor: 2.29). 01/2012;

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Page 1

Page 2

Please
Epilepsy
cite
this
article
in
press
as:
Serrano-Castro,
P.J.,
et
al.,
Predictive
model
for
refractoriness
in
Temporal
Lobe
based
on
clinical
and
diagnostic
test
data.
Epilepsy
Res.
(2012),
doi:10.1016/j.eplepsyres.2012.03.009
ARTICLE IN PRESS
+Model
EPIRES-4734;

No.
of
Pages
9
2

P.J.
Serrano-Castro
et
al.
reported
of
ical
of
firmed
and
of
to
patients
ment
The
sible
syndromes,
Hippocampal
ropsychological
attributable
by
Ebner,
surgery
cal
and
quality
isolation,
and
been
drug
is
Tomson
treated
disease
tiple
An
refractory
tionally
few
lishing
2006;
a
tolerated
combination
sometimes
the
ability
criteria
RE
most
logical
with
patients
by
TLE
mental
ment
and
ral
2006;
2011).
In
four
ables
et
Aguglia
to
achieve
complete
seizure
remission
in
40—90%
patients
with
refractory
TLE,
depending
on
the
patholog-
substrate
(Spencer
and
Hugh,
2008). The
effectiveness
anterior
temporal
lobectomy
for
refractory
TLE
was
con-
by
a
controlled
clinical
trial
(Wiebe
et
al.,
2001),
a
recent
meta-analysis
concluded
that
the
combination
surgery
and
medical
treatment
was
four-fold
more
likely
completely
eradicate
seizures
in
appropriately
selected
with
refractory
TLE
in
comparison
to
medical
treat-
alone
(Schmidt
and
Stavem,
2009).
surgical
decision
should
be
made
as
early
as
pos-
in
these
patients.
The
most
frequent
refractory
TLE
such
as
Mesial
Temporal
Lobe
Epilepsy
with
Sclerosis
(MTLE-HS),
produce
progressive
neu-
impairment
throughout
their
natural
history,
to
repeated
seizures
that
can
only
be
prevented
non-pharmacological
means,
such
as
surgery
(Jokeit
and
1999;
Helmstaedter
and
Elger,
2009). A
delay
in
implies
long-term
polytherapy
with
complex
medi-
treatments,
which
are
associated
with
adverse
cognitive
systemic
effects
(Carre˜ no
et
al.,
2008) that
impair
the
of
life
of
epilepsy
patients
(Berto,
2002). The
social
academic
failure,
and
inability
to
achieve
work
life
goals
that
characterize
patients
with
epilepsy
have
related
to
their
repeated
seizures
and
antiepileptic
(AED)
treatments
(Engel,
2004), and
the
mortality
risk
increased
by
seizure
repetition
(Sperling
et
al.,
1999;
et
al.,
2008). Nevertheless,
these
patients
are
not
with
surgery
(when
available)
until
20
years
after
onset
(Engel
et
al.,
2003) and
after
undergoing
mul-
unsuccessful
therapeutic
trials
(Berg,
2008).
additional
factor
in
this
delay
is
that
the
concept
of
epilepsy
(RE)
has
only
recently
become
interna-
accepted
(Kwan
et
al.,
2010); therefore,
there
are
published
data
for
results
comparison
and
for
estab-
consensus
guidelines
(Perucca,
1998;
Berg
et
al.,
Arzimanoglou
and
Ryvlin,
2008). The
ILAE
proposed
definition
of
RE
as
the
failure
of
adequate
trials
of
two
and
appropriate
AED
regimens
in
monotherapy
or
(Kwan
et
al.,
2010). However,
a
long
period
can
elapse
before
this
condition
is
met,
during
which
patient’s
quality
of
life
continues
to
deteriorate.
The
to
predict
refractoriness
before
patients
fulfill
ILAE
would
therefore
be
of
high
clinical
value.
has
been
studied
by
various
authors,
and
the
factor
consistently
related
to
its
development
is
the
patho-
substrate.
The
condition
most
frequently
associated
treatment
resistance
is
MTL-HS,
with
reports
that
these
have
an
89%
likelihood
of
developing
RE,
followed
cortical
dysplasias
(Semah
et
al.,
1998). Refractoriness
in
has
also
been
related
to:
early
onset,
long
time
course,
retardation,
lack
of
response
to
first
AED,
require-
for
polytherapy,
detection
of
focal
alterations
in
EEG,
radiologic
evidence
of
HS
or
structural
lesion
in
tempo-
lobe
(Kim
et
al.,
1999;
Dlugos
et
al.,
2001;
Spooner
et
al.,
Varoglu
et
al.,
2009;
Pittau
et
al.,
2009;
Aguglia
et
al.,
an
exhaustive
review
of
the
literature,
we
detected
studies
on
the
relationship
between
clinical
TLE
vari-
and
the
development
of
treatment
resistance
(Falip
al.,
2003;
Varoglu
et
al.,
2009;
Pittau
et
al.,
2009;
et
al.,
2011), but
only
partial
data
were
analyzed,
results
of
relationship
and
The
clinical
develop
teristics,
to
teria.
were
always
negative,
and
there
was
no
discussion
semiological
issues.
We
found
no
report
on
the
possible
between
a
specific
neuropsychological
profile
the
development
of
treatment
resistance.
objectives
of
this
study
were:
to
describe
the
early
and
diagnostic
characteristics
of
TLE
patients
who
RE,
to
stratify
RE
risk
as
a
function
of
these
charac-
and
to
propose
a
predictive
model
for
progression
refractory
TLE
based
on
clinical
and
diagnostic
test
cri-
Material and
methods
This
patients
at
Unit
(Spain).
patient
epileptic
criteria
neuroimaging
a
interictal
A
the
unsuccessfully
ate
et
patients.
Sampling
age
to
by
ability
reliably
with
records
EEG
quality
tunity
Exclusion
cion
epilepsy.
epidemiological
case—control
study
was
performed
in
with
a
confirmed
diagnosis
of
TLE
under
follow-up
the
Neurology
and
Neurophysiology
Clinical
Management
of
the
Torrecardenas
Hospital
Complex
in
Almeria
The
diagnosis
of
TLE
was
considered
when
the
experienced
paroxysmal
episodes
compatible
with
seizures
of
temporal
origin
according
to
clinical
and
there
was
also
a
structural
lesion
evidenced
by
techniques
in
one
or
both
temporal
lobes
or
persistent
electrical
anomaly
in
temporal
areas
in
ictal
or
EEG
records.
case
group
was
formed
by
the
patients
who
met
2010
ILAE
definition
of
RE,
i.e.,
those
who
had
been
treated
with
two
tolerated
and
appropri-
AED
regimens
in
monotherapy
or
combination
(Kwan
al.,
2010). A
control
group
was
formed
by
the
remaining
was
consecutive.
Study
inclusion
criteria
were:
≥16
years;
capacity
of
the
patient
or
direct
relative
give
reliable
information
on
study
variables
(as
assessed
the
researcher);
follow-up
period
of
≥1
year;
avail-
of
adequate
data
on
clinical
variables
or
ability
to
gather
any
missing
data
by
prospective
interview
patient
or
relative;
history
of
at
least
2
interictal
EEG
separated
by
>3
months
or
a
prospective
video-
monitoring
study;
and
a
brain
MRI
study
of
adequate
following
a
specific
epilepsy
protocol
or
the
oppor-
to
obtain
a
prospective
study
of
these
characteristics.
criteria
were
the
presence
or
well-founded
suspi-
of
psychogenic
pseudo-seizures
and
previous
surgery
for
Definition
of
variables
The
ment,
(predictive)
age
(CNS)
of
(Commission
1981),
non-automatic
ization,
etiological
ropsychological
type
dependent
variable
was
refractoriness
to
medical
treat-
defined
according
to
ILAE
2010
criteria.
Independent
variables
were:
sex,
years
since
epilepsy
onset,
at
first
seizure,
history
of
central
nervous
system
infection,
history
of
febrile
convulsions
(FCs),
type
prevalent
seizure
according
to
the
ILAE
classification
on
Classification
and
Terminology
of
the
ILAE,
presence
of
aura,
automatic
behavior
during
seizures,
ictal
motor
behavior,
secondary
general-
number
of
AEDs
being
taken
at
study
inclusion,
classification,
neurophysiological
findings,
neu-
assessment,
and
previous
CNS
surgery
of
any
except
for
epilepsy
surgery
(see
exclusion
criteria).

Page 3

Please
Epilepsy
cite
this
article
in
press
as:
Serrano-Castro,
P.J.,
et
al.,
Predictive
model
for
refractoriness
in
Temporal
Lobe
based
on
clinical
and
diagnostic
test
data.
Epilepsy
Res.
(2012),
doi:10.1016/j.eplepsyres.2012.03.009
ARTICLE IN PRESS
+Model
EPIRES-4734;

No.
of
Pages
9
Refractoriness
in
Temporal
Lobe
Epilepsy

3
The
etiology
was
classified
in
three
groups
according
to
unknown
group
group
other
The
visual
test
Spanish-TAVEC]),
visual—perceptual/visual
Cubes
association
normal
findings.
Study
rospective
hoc
patients
cal
or
record,
or
the
neuroimaging
results
and
following
ILAE
criteria:
origin
group
(normal
neuroimaging),
MTLE-HS
(neuroimaging
compatible
with
HS),
and
structural
(neuroimaging
compatible
with
structural
disease
than
HS).
neuropsychological
assessment
comprised
five
tests:
memory
test
(complex
Rey
figure),
verbal
memory
(Spain-Complutense
verbal
learning
test
[initials
in
verbal
fluency
test
(Boston
Naming
Test),
constructive
function
test
(WAIS
III),
and
executive
function
test
(controlled
oral
word
test
[COWAT]).
Test
results
were
classified
as
or
pathological
by
comparison
with
control
group
data
were
gathered
as
follows
(in
this
order):
ret-
analysis
of
clinical
history
by
means
of
an
ad
structured
questionnaire;
personal
interview
with
the
and
relatives
to
collect
data
missing
from
the
clini-
history;
performance
of
complementary
tests
for
absent
discrepant
data,
including
interictal
EEG,
ictal
video-EEG
high-resolution
MRI
with
specific
epilepsy
protocol,
standard
neuropsychological
battery.
Statistical
analysis
The
to
expressed
(range,
Student’s
used
and
compare
cant
correlation
model,
diagnostically
tion
odds
multivariate
ing
independent
their
was
We
predictive
diagnostic
analysis,
construct
and
order
TLE.
The
these
Shapiro—Wilks
or
Kolmogorov—Smirnov
tests
were
used
assess
the
normality
of
continuous
variables,
which
were
as
mean
(standard
deviation
[SD])
or
median
maximum
and
minimum
values)
accordingly.
The
t
or
Mann—Whitney
U
test,
as
appropriate,
were
to
compare
continuous
variables
between
the
groups,
the
chi-square
or
Fischer’s
exact
test
were
used
to
categorical
variables.
Variables
showing
a
signifi-
relationship
with
the
dependent
variable
in
bivariate
analyses
were
entered
into
a
logistic
regression
along
with
variables
considered
highly
clinically
or
relevant,
using
the
estimation
change
estima-
method
to
assess
confounding
factors
and
calculating
ratios
(ORs)
with
confidence
intervals
(CIs).
Finally,
a
analysis
was
performed
to
control
for
confound-
factors.
Based
on
the
regression
coefficients
(?)
of
the
variables
entered
into
the
model,
we
obtained
OR
with
95%
CI.
SPSS
Version
17
(SPSS
Inc,
Chicago,
IL)
used
for
the
above
analyses.
then
calculated
the
positive
(PPV)
and
negative
(NPV)
values
and
positive
likelihood
ratio
(PLR)
of
the
variables
that
were
significant
in
the
multivariate
both
individually
and
in
combination,
in
order
to
a
refractoriness
prediction
model;
both
refractory
non-refractory
groups
were
included
in
the
analysis
in
to
develop
a
predictive
model
for
all
patients
with
Epidat
version
3.1
statistical
package
was
used
for
calculations.
Results
Out
refractoriness
met
of
the
163
TLE
patients
included
in
the
study,
ILAE-2010
criteria
were
met
by
83
(50.9%)
and
were
not
by
80
(49.1%);
84
(51.5%)
were
female,
79
(48.5%)
were
male.
mean
and
from
The
age
at
onset
ranged
from
0
to
74
years,
with
a
of
20.39
years
(SD
=
16.61)
and
median
of
16
years,
the
mean
time
from
diagnosis
to
study
inclusion
ranged
1
to
77
years,
with
a
mean
of
24.58
years
(SD
=
15.71).
The
etiology
was
unknown
in
67
patients
(41.1%)
and
structural
ria
44
in
subgroup.
Nineteen
infancy,
HS
Fourteen
during
The
seizures
I.B2
seizures
seizures
the
Auras
was
racic
77
(déjà
time-passing)
tatory,
the
Out
or
of
(82.7%),
Patients
Some
was
data
anamnesis).
Out
never
reported
since
The
2.15
The
structural
brain
tumors,
malformations
angiomas,
Sturge-Weber
(6
and
cephalies
unknown
2
showing
Out
data
focal
activity
remaining
in
52
(31.9%),
while
MTLE-HS
radiological
crite-
were
met
in
the
remaining
44
patients
(27%).
Among
the
MTLE-HS
patients,
an
additional
alteration
was
observed
the
MRI
study
of
7
patients,
who
formed
a
dual-pathology
patients
(11.6%)
had
a
history
of
FC
during
first
which
was
considerably
more
frequent
in
the
MTLE-
group
(20.5%)
than
in
the
unknown-etiology
group
(1.9%).
patients
(8.64%)
had
a
history
of
CNS
infection
first
infancy.
predominant
seizure
type
was
I.B.1
(complex
partial
[CPS]
with
aura)
in
96
(58.9%)
of
the
patients,
type
(without
aura)
in
52
(31.9%),
type
1.A
(simple
partial
[SPS]
alone)
in
14
(8.64%),
and
type
1.C
(partial
with
secondary
generalization)
in
1
patient;
out
of
14
patients
with
type
I.A
seizures,
4
had
motor
SPS
alone.
were
experienced
by
106
patients
(65%);
the
aura
visceral
(epigastric
sensation,
cephalic
oppression,
tho-
oppression,
dizziness,
sweating,
or
piloerection)
in
of
these
patients
(72.6%),
experiential
or
cognitive
vu,
derealization,
fear,
forced
thought,
pleasure,
fast
in
34
(32%),
and
sensory
(visual,
olfactory,
gus-
auditory
type
or
paresthesia
in
tongue
or
genitals)
in
remaining
19
patients
(17.9%).
of
the
160
patients
with
available
video-EEG
records
reliable
information,
122
(74.8%)
showed
some
type
automatism,
which
was
oroalimentary
in
101
patients
manual
in
78
(63.9%),
and
complex
in
14
(11.4%).
frequently
had
more
than
one
type
of
automatism.
type
of
motor
behavior,
predominantly
cephalic,
found
in
23
(16.6%)
of
the
138
patients
for
whom
reliable
were
available
(video-EEG
monitoring
or
irrefutable
of
the
163
patients
in
the
series,
23.3%
had
experienced
secondary
generalization,
whereas
32.5%
more
than
10
generalized
tonic—clonic
seizures
epilepsy
onset.
mean
number
of
AEDs
received
by
the
patients
was
(SD
=
0.99;
range
0—4).
59
cases
with
structural
etiology
(52
with
isolated
lesion
and
7
with
dual
disease)
comprised:
17
tumors
(12
low
grade
glial
tumors,
3
neuroectodermal
1
lipoma,
and
1
meningioma),
11
temporal
vascular
(6
arteriovenous
malformations,
3
cavernous
1
telangiectasis,
and
1
angioma
associated
with
syndrome),
8
cortical
development
disorders
focal
cortical
dysplasias,
1
subependymal
heterotopia,
1
hamartoma
in
tuberous
sclerosis),
7
temporal
poren-
(5
ischemic
vascular,
1
postsurgical,
and
1
of
origin),
5
temporal
glioses
(3
post-traumatic
and
post-encephalitic),
and
11
miscellaneous
cases,
mostly
sequelae
of
connatal
encephalopathies.
of
the
149
patients
for
whom
neurophysiologic
test
were
available,
96
(64.4%)
evidenced
some
type
of
alteration,
67
(44.9%)
some
type
of
epileptiform
(spikes,
spikes-waves,
or
acute
waves),
and
the
29
(19.4%)
slow
activity.

Page 4

Page 5

Page 6

Please
cite
this
article
in
press
as:
Serrano-Castro,
P.J.,
et
al.,
Predictive
model
for
refractoriness
in
Temporal
Lobe
Epilepsy
based
on
clinical
and
diagnostic
test
data.
Epilepsy
Res.
(2012),
doi:10.1016/j.eplepsyres.2012.03.009
ARTICLE IN PRESS
+Model
EPIRES-4734;

No.
of
Pages
9
6

P.J.
Serrano-Castro
et
al.
Table
value.
6

Refractoriness
prediction
model
based
on
the
significant
independent
variables.
PPV:
positive
predictive
value.
PLR:
positive
likelihood
ratio.
NPV:
negative
predictive
Variable
or
combination
of
variables

PPV
%
(95%
CI)

PLR
(95%
CI)

NPV%
(95%
CI)

Number
group/number
in
of
patients
in
the
of
patients
global
series
(%)
Focal
Presence
Structural
Presence
interictal
Presence
MRI
Focal
lesion
IED
MRI
Presence
interictal
Presence
interictal
(including
Presence
interictal
(including
anomalies
in
interictal
EEGs

60.61
62.3
63.16
72.00
(50.48—70.74)

1.48
1.59
1.65
2.48
(1.14—1.93)

64.06
82.93
66.18
67.05
(51.53—76.6)

99/163
122/163
95/163
75/163
(60.73%)
of
automatisms
(53.29—71.3)
(1.3—1.94)
(70.19—95.66)
(74.84%)
lesion
in
MRI
(including
HS)
(52.93—73.38)
(1.25—2.19)
(54.2—78.16)
(58.28%)
of
automatisms
+
focal
anomalies
in
EEGs
(61.17—82.83)
(1.66—3.70)
(56.66—77.43)
(46.01%)
of
automatisms
+
structural
lesion
in
(including
HS)
72.6
(61.69—83.52)

2.55
(1.69—3.86)

66.67
(56.37—76.96)

73/163
(44.78%)
anomalies
in
interictal
EEGs
+
structural
in
MRI
(including
HS)
73.33
(61.31—85.36)

2.65
(1.64—4.3)

62.14
(52.28—71.99)

60/163
(36.81%)
in
interictal
EEGs
+
structural
lesion
in
(including
HS)
75.00
(61.07—88.93)

2.89
(1.57—5.32)

57.98
(48.69—67.27)

44/163
(26.99%)
of
automatisms
+
focal
anomalies
in
EEGs
+
HS
in
MRI
81.25
(66.16—96.34)

4.18
(1.82—9.61)

56.49
(47.62—65.36)

32/163
(19.63%)
of
any
type
of
automatism
+
IED
in
EEG
+
structural
lesion
in
MRI
HS)
84.38
(70.23—98.52)

5.20
(2.11—12.85)

57.25
(48.40—66.11)

32/163(19.63%)
of
automatisms
+
focal
anomalies
in
EEGs
+
structural
lesion
in
MRI
HS)
84.44
(72.74—96.14)

5.23
(2.48—11.03)

61.86
(52.68—71.05)

45/163
(27.6%)

Page 7

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Epilepsy
cite
this
article
in
press
as:
Serrano-Castro,
P.J.,
et
al.,
Predictive
model
for
refractoriness
in
Temporal
Lobe
based
on
clinical
and
diagnostic
test
data.
Epilepsy
Res.
(2012),
doi:10.1016/j.eplepsyres.2012.03.009
ARTICLE IN PRESS
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No.
of
Pages
9
Refractoriness
in
Temporal
Lobe
Epilepsy

7
(Kim
Varoglu
We
ness
(Falip
but
et
observed
and
FC
postulates
for
We
tion
et
et
previous
TLE
With
significantly
presence
of
behavior,
There
ological
the
ciated
et
2009)
consciousness
postures,
eralization
investigated
seizures;
ness
p
sign
Risinger,
ing
presence
We
mesial
roimaging
may
area,
of
prognosis,
(Hennessy
ity
clinical
We
of
are
patients.
sole
ing
with
predominant
83.3%
Hence,
toriness
manifestation.
et
al.,
1999;
Falip
et
al.,
2003;
Pittau
et
al.,
2009;
et
al.,
2009).
found
no
significant
association
between
refractori-
and
a
history
of
FC,
in
agreement
with
some
authors
et
al.,
2003;
Spooner
et
al.,
2006;
Varoglu
et
al.,
2009)
in
disagreement
with
others
(Kim
et
al.,
1999;
Hitiris
al.,
2007;
Pittau
et
al.,
2009;
Aguglia
et
al.,
2011). We
a
correlation
between
radiological
evidence
of
HS
a
history
of
FC,
which
may
explain
the
association
with
observed
in
some
studies.
Our
finding
supports
clinical
regarding
a
possible
common
genetic
substrate
FC
and
HS
(Baulac
et
al.,
2001;
Claes
et
al.,
2004).
found
no
association
between
a
history
of
CNS
infec-
and
refractoriness,
confirming
previous
findings
(Kim
al.,
1999;
Falip
et
al.,
2003;
Spooner
et
al.,
2006;
Varoglu
al.,
2009), and
it
appears
adequately
demonstrated
that
CNS
infection
does
not
imply
a
worse
prognosis
in
patients.
regard
to
semiological
variables,
refractoriness
was
associated
with
the
type
of
seizure
and
the
of
automatisms
but
not
with
the
presence
or
type
aura,
the
presence
or
type
of
non-automatic
ictal
motor
or
the
development
of
secondary
generalization.
have
been
few
studies
on
the
prognostic
value
of
semi-
data
in
TLE.
Different
authors
have
reported
that
development
of
refractoriness
is
not
significantly
asso-
with
the
presence
of
secondary
generalization
(Pittau
al.,
2009;
Varoglu
et
al.,
2009) or
auras
(Varoglu
et
al.,
or
with
auditory
symptoms,
autonomic
symptoms,
impairment,
déjà
vu,
dysphasia,
dystonic
drop
attacks,
epigastric
aura,
or
secondary
gen-
(Aguglia
et
al.,
2011). None
of
these
studies
the
presence
of
automatic
behaviors
during
therefore,
its
strong
correlation
with
refractori-
in
the
present
study
(OR
=
7.317;
95%
CI
2.98—17.964;
=
<0.001)
is
a
novel
finding.
Although
automatisms
are
a
of
MTLE-HS
(Delgado-Escueta
et
al.,
1992;
Gil-Nagel
and
1997) and
could
therefore
represent
a
confound-
factor,
our
multivariate
analysis
confirmed
that
their
behaves
as
an
independent
predictive
variable.
propose
that
the
refractoriness
may
be
associated
with
lesions
that
cannot
be
visualized
with
available
neu-
techniques
and
that
the
presence
of
automatisms
therefore
serve
as
an
early
marker
of
damage
of
this
consistent
with
the
above-cited
studies.
The
presence
automatisms
has
been
related
to
an
improved
postsurgical
although
statistical
significance
was
not
reached
et
al.,
2001), further
supporting
the
desirabil-
of
an
early
surgical
decision
in
patients
with
MTLE
and
or
video-EEG
evidence
of
automatic
behavior.
highlight
the
protective
role
against
refractoriness
the
presence
of
type
I.A
seizures
alone.
Epileptic
auras
highly
characteristic
of
TLEs
and
are
present
in
90%
of
However,
cases
in
which
type
I.A
seizures
are
the
TLE
manifestation
are
much
less
frequent,
represent-
only
around
8%
of
our
series
and
forming
a
subgroup
differential
characteristics.
In
contrast,
CPS
was
the
seizure
in
97.6%
of
our
refractory
cases
versus
of
our
non-refractory
cases,
a
significant
difference.
it
appears
exceptional
for
a
TLE
to
meet
refrac-
criteria
if
CPS
is
not
the
predominant
clinical
As
previously
reported,
refractoriness
was
associated
with
combination)
mum
2001,
response
TLE.
addition
(Mohanraj
in
of
which
(1999).
Our
radiological
ogy
presence
who
Dlugos
et
et
tural
of
Pittau
regard
ogy,
were
tions
reports
In
whether
conferred
significance
ered.
Kim
Pittau
significant
The
cal
attributed
tivity
et
frequent
tory
did
which
In
associated
during
ing
(focal
CNS
significant
combinations.
observed
variables,
treatment
ate
PPV
was
MRI
decision
the
need
for
antiepileptic
polytherapy
(≥3
AEDs
in
and
for
surgery,
which
represent
the
maxi-
therapeutic
effort
required
by
refractory
patients.
In
Dlugos
et
al.
assigned
a
strong
prognostic
value
to
the
to
the
first
AED
in
children
newly
diagnosed
with
Subsequent
studies
found
that
replacement
with
or
of
a
second
AED
was
effective
in
27—32%
of
patients
and
Brodie,
2005) but
that
any
further
increase
the
number
AEDs
benefited
only
a
very
small
percentage
patients.
The
above
data
are
congruent
with
our
results,
were
also
similar
to
the
findings
reported
by
Kim
et
al.
finding
of
an
association
between
refractoriness
and
evidence
of
HS,
structural
lesion,
or
dual
pathol-
confirms
previous
reports,
especially
with
respect
to
the
of
HS,
which
is
highlighted
by
almost
all
authors
have
analyzed
TLE
prognostic
factors
(Kim
et
al.,
1999;
et
al.,
2001;
Mohanraj
and
Brodie,
2005;
Spooner
al.,
2006;
Pittau
et
al.,
2009;
Varoglu
et
al.,
2009;
Aguglia
al.,
2011). However,
the
influence
of
other
types
of
struc-
lesion
is
more
controversial;
a
significant
relationship
non-HS
structural
lesion
with
refractoriness
was
found
by
et
al.
(2009)
but
not
by
Spooner
et
al.
(2006).
With
to
the
underlying
disease,
we
found
that
dual
pathol-
HS,
glial
tumors,
and
cortical
development
disorders
related
to
refractoriness
but
that
vascular
malforma-
and
porencephalies
were
not,
in
line
with
previous
(Semah
et
al.,
1998;
Liimatainen
et
al.,
2008).
our
series,
alterations
in
interictal
EEG
records,
interictal
epileptiform
discharges
(IEDs)
or
not,
a
risk
of
refractoriness
development,
although
was
not
reached
when
IEDs
alone
were
consid-
Our
findings
are
highly
similar
to
those
published
by
et
al.
(1999),
Spooner
et
al.
(2006)
(in
children),
and
et
al.
(2009), while
Aguglia
et
al.
(2011)
did
not
obtain
results.
frontal
deficits
detected
in
our
neuropsychologi-
examination
are
frequently
reported
in
TLE
and
are
to
a
probable
disruption
of
the
normal
connec-
of
temporal
lobes
with
anterior
structures
(Martin
al.,
2000). A
novel
finding
of
our
study
was
the
more
presence
of
frontal
executive
deficits
in
refrac-
versus
non-refractory
patients;
although
the
difference
not
reach
statistical
significance
(p
=
0.008;
see
Table
4),
can
likely
be
attributed
to
our
small
sample
size.
the
multivariate
analysis,
the
independent
variables
with
refractoriness
were:
automatic
behavior
seizure,
structural
lesion
in
neuroimaging
(includ-
findings
compatible
with
HS),
pathological
interictal
EEG
slowing
or
IED),
receipt
of
polytherapy,
and
previous
surgery.
Table
6
shows
the
PPV,
NPV
and
PLR
of
each
diagnostic
variable
and
of
their
different
possible
A
PPV
of
84.78%
(95%CI;
73.32—96.25%)
was
for
the
combined
presence
of
the
three
diagnostic
when
the
likelihood
of
refractoriness
to
medical
would
be
sufficiently
high
to
order
an
immedi-
pre-surgical
study
of
the
patient.
In
this
situation,
the
was
reduced
to
72.6%
(95%CI;
61.69—83.52%)
if
the
EEG
normal
and
to
73.33%
(95%
CI;
62.66—84.01%)
if
the
was
normal.
Based
on
these
results,
we
constructed
a
algorithm
for
TLE
(Fig.
2)
that
could
represent
a

Page 8

Page 9

Please
Epilepsy
cite
this
article
in
press
as:
Serrano-Castro,
P.J.,
et
al.,
Predictive
model
for
refractoriness
in
Temporal
Lobe
based
on
clinical
and
diagnostic
test
data.
Epilepsy
Res.
(2012),
doi:10.1016/j.eplepsyres.2012.03.009
ARTICLE IN PRESS
+Model
EPIRES-4734;

No.
of
Pages
9
Refractoriness
in
Temporal
Lobe
Epilepsy

9
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Pedro Serrano Castro

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Predictive model for refractoriness in Temporal Lobe Epilepsy based on clinical and diagnostic test data.

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