Transsylvian-Transcisternal Selective Lesionectomy for Pediatric Lesional Mesial Temporal Lobe Epilepsy

Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, College of Medicine, Seoul, Republic of Korea.
Neurosurgery (Impact Factor: 3.62). 03/2011; 68(3):582-7. DOI: 10.1227/NEU.0b013e3182077552
Source: PubMed


The optimal extent of resection for surgical treatment of lesional epilepsy is a controversial issue.
For patients with mesial temporal lobe lesions visible on magnetic resonance imaging, we compared the surgical outcome of selective lesionectomy with that of standard anterior temporal lobectomy (ATL) and amygdalohippocampectomy.
We conducted a retrospective analysis of the seizure outcome of 40 patients treated for lesional mesial temporal lobe epilepsy between 1993 and 2008. Before 2006, patients were managed by ATL (n=29) and from 2006 onward, by selective lesionectomy via the transsylvian-transcisternal approach (n=11).
The postoperative seizure-free rates for the 2 groups were comparable: 93% (27/29) for the ATL group and 91% (10/11) for the selective lesionectomy group (P=.814). In both groups, patients with persistent seizures commonly showed incomplete lesion resection, with complete resection often improving seizure outcome. Postoperative visual field defects were more common in the ATL group (21%) than in the selective lesionectomy group (0%) (P=.102).
Transsylvian-transcisternal selective lesionectomy is an effective and safe therapeutic modality in children with lesional mesial temporal lobe epilepsy. Completeness of resection is an important variable for seizure control regardless of surgical modality.

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    ABSTRACT: Temporal lobe epilepsy (TLE) is the most common form of epilepsy in adults and is responsible for 15%-20% of epilepsy cases in children. Class I evidence strongly supports the use of temporal lobectomy for intractable TLE in adults, but fewer studies have examined seizure outcomes and predictors of seizure freedom after temporal lobectomy in pediatric patients. The authors performed a systematic review and meta-analysis of studies including 10 or more pediatric patients (age ≤ 19 years) published over the last 20 years examining seizure outcomes after temporal lobectomy for TLE. Thirty-six studies met their inclusion criteria. These 36 studies included 1318 pediatric patients with a mean age (± SEM) of 10.7 ± 0.3 years. Overall, seizure freedom (Engel Class I outcome) was achieved in 1002 cases (76%); 316 patients (24%) continued to have seizures (Engel Class II-IV outcome). All patients had at least 1 year of follow-up. Statistically significant predictors of seizure freedom after surgery included lesional epilepsy etiology (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.02-1.15), abnormal findings on preoperative MRI (OR 1.27, 95% CI 1.16-1.40), and lack of generalized seizures (OR 1.36, 95% CI 1.20-1.56). Among lesional epilepsy cases, there was a trend toward better outcome with gross-total lesionectomy than with subtotal resection. Approximately three-fourths of pediatric patients with TLE attain seizure freedom after temporal lobectomy. Favorable outcomes may be predicted by lesional epilepsy etiology, abnormal MRI, and lack of generalized seizures. Pediatric patients with medically refractory TLE should be referred to a comprehensive pediatric epilepsy center for surgical evaluation.
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