Day: December 13, 2017

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Surgical Treatment of Mesiotemporal Lobe Epilepsy: Which Approach is Favorable?

Neurosurgery 81:992–1004, 2017

Mesiotemporal lobe epilepsy is one of the most frequent causes for pharmacoresistant epilepsy. Different surgical approaches to the mesiotemporal area are used.

OBJECTIVE: To analyze epileptological and neuropsychological results as well as complications of different surgical strategies.

METHODS: This retrospective study is based on a consecutive series of 458 patients all harboring pharmacoresistant mesiotemporal lobe epilepsy. Following procedures were performed: standard anterior temporal lobectomy, anterior temporal or key-hole resection, extended lesionectomy, and transsylvian and subtemporal selective amygdalohippocampectomy. Postoperative outcome was evaluated according to different surgical procedures.

RESULTS: Overall, 1 yr after surgery 315 of 432 patients (72.9%) were classified Engel I; in particular, 72.8% were seizure-free after anterior temporal lobectomy, 76.9% after key-hole resection, 84.4% after extended lesionectomy, 70.3% after transylvian selective amygdalohippocampectomy, and 59.1% after subtemporal selective amygdalohippocampectomy. No significant differences in seizure outcome were found between different resective procedures, neither in short-term nor long-term follow-up. There was no perioperative mortality. Permanent morbidity was encountered in 4.4%. There were no significant differences in complications between different resection types. In the majority of patients, selective attention improved following surgery. Patients after left-sided operations performed significantly worse regarding verbal memory as compared to right-sided procedures. However, surgical approach had no significant effect on memory outcome.

CONCLUSION: Different surgical approaches for mesiotemporal epilepsy analyzed resulted in similar epileptological, neuropsychological results, and complication rates. Therefore, the approach for the individual patient does not only depend on the specific localization of the epileptogenic area, but also on the experience of the surgeon.

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Stereotactic Radiosurgery for Brainstem Arteriovenous Malformations

Neurosurgery 81:910–920, 2017

The management of brainstem arteriovenous malformations (bAVMs) is a formidable challenge. bAVMs harbor higher morbidity and mortality compared to other locations.

OBJECTIVE: To review the outcomes following stereotactic radiosurgery (SRS) of bAVMs in a multicenter study.

METHODS: Six medical centers contributed data from 205 patients through the International Gamma Knife Research Foundation. Median age was 32 yr (6-81). Median nidus volume was 1.4 mL (0.1-69 mL). Favorable outcome (FO) was defined as AVM obliteration and no post-treatment hemorrhage or permanent symptomatic radiation-induced complications.

RESULTS: Overall obliteration was reported in 65.4% (n = 134) at a mean follow-up of 69 mo. Obliteration was angiographically proven in 53.2% (n = 109) and on MRA in 12.2% (n=25). Actuarial rate of obliteration at 2, 3, 5, 7, and 10 yr after SRS was 24.5%, 43.3%, 62.3%, 73%, and 81.8% respectively. Patients treated with a margin dose >20 Gy were more likely to achieve obliteration (P = .001). Obliteration occurred earlier in patients who received a higher prescribed margin dose (P = .05) and maximum dose (P = .041). Post-SRS hemorrhage occurred in 8.8% (n = 18). Annual post gamma knife latency period hemorrhage was 1.5%. Radiation-induced complications were radiologically evident in 35.6% (n = 73), symptomatic in 14.6% (n=30), and permanent in 14.6% (n=30, which included long-tract signs and new cranial nerve deficits). FO was achieved in 64.4% (n = 132). Predictors of an FO were a higher Virginia radiosurgery AVM scale score (P = .003), prior hemorrhage (P = .045), and a lower prescribed maximum dose (P = .006).

CONCLUSION: SRS for bAVMs results in obliteration and avoids permanent complications in the majority of patients.

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