Functional Neurosurgery: Epilepsy Surgery Functional Neurosurgery: Epilepsy Surgery Kim J. Burchiel, M.D., F.A.C.S. Department of Neurological Surgery Oregon Health and Science University Kim J. Burchiel, M.D., F.A.C.S. Department of Neurological Surgery Oregon Health and Science University
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Functional Neurosurgery: Epilepsy Surgery · 2015-11-12 · Epilepsy Surgery: History • Frederic and Erma Gibbs working with Percival Bailey (U. of Illinois 1947) – Temporal lobectomy
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Functional Neurosurgery:Epilepsy Surgery
Functional Neurosurgery:Epilepsy Surgery
Kim J. Burchiel, M.D., F.A.C.S.Department of Neurological Surgery
Oregon Health and Science University
Kim J. Burchiel, M.D., F.A.C.S.Department of Neurological Surgery
Oregon Health and Science University
Epilepsy SurgeryEpilepsy Surgery
• 2 million in US have epilepsy• 400,000-600,000 medically intractable
– 25% candidates for epilepsy surgery• 1500 epilepsy surgery procedures done
in US per year• Cost of epilepsy surgery << lifetime
disability from epilepsy
• 2 million in US have epilepsy• 400,000-600,000 medically intractable
– 25% candidates for epilepsy surgery• 1500 epilepsy surgery procedures done
in US per year• Cost of epilepsy surgery << lifetime
disability from epilepsy
Epilepsy SurgeryEpilepsy Surgery
• J.E. Engle, M.D., Ph.D. (UCLA)– “In all of modern medicine, few generally
accepted therapeutic interventions are as underutilized as surgical treatment for epileptic seizures.”
• J.E. Engle, M.D., Ph.D. (UCLA)– “In all of modern medicine, few generally
accepted therapeutic interventions are as underutilized as surgical treatment for epileptic seizures.”
Epilepsy Surgery: HistoryEpilepsy Surgery: History
• Dr Benjamin Dudley– Trephinated 5 patients for focal motor seizures
(Transylvania Univ - Kentucky 1818-1827)• All 5 lived• 3 became seizure-free
• Hughings Jackson – Convinces Sir Victor Horsley to operate on 3
patients with post-traumatic seizures (National Hospital - London 1886)
• 2 became seizure-free
• Dr Benjamin Dudley– Trephinated 5 patients for focal motor seizures
(Transylvania Univ - Kentucky 1818-1827)• All 5 lived• 3 became seizure-free
• Hughings Jackson – Convinces Sir Victor Horsley to operate on 3
patients with post-traumatic seizures (National Hospital - London 1886)
• 2 became seizure-free
Epilepsy Surgery: HistoryEpilepsy Surgery: History
• Frederic and Erma Gibbs working with Percival Bailey (U. of Illinois 1947)– Temporal lobectomy
• Clinical localization
• Herbert Jasper and Wilder Penfield (Montreal Neurological Institute)– Temporal lobectomy
• Visible pathology– Epilepsy and the Functional Anatomy of the
Human Brain
• Frederic and Erma Gibbs working with Percival Bailey (U. of Illinois 1947)– Temporal lobectomy
• Clinical localization
• Herbert Jasper and Wilder Penfield (Montreal Neurological Institute)– Temporal lobectomy
• Visible pathology– Epilepsy and the Functional Anatomy of the
• Randomized controlled trial– Mesial temporal lobe surgery (n=40)– Antiepileptic drug therapy (n=40)
• Evaluated by two blinded neurologists– Record review only
• Randomized controlled trial– Mesial temporal lobe surgery (n=40)– Antiepileptic drug therapy (n=40)
• Evaluated by two blinded neurologists– Record review only
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
• Primary outcome measure– Freedom from seizures impairing
awareness (Engle class I)• Complex partial or generalized
• Primary outcome measure– Freedom from seizures impairing
awareness (Engle class I)• Complex partial or generalized
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
• Four patients assigned to surgery did not undergo surgery (intent to treat paradigm)– 1: declined surgery, 2: data inconsistent, 1:
no seizures during monitoring• Six patients had subdural electrode
recording
• Four patients assigned to surgery did not undergo surgery (intent to treat paradigm)– 1: declined surgery, 2: data inconsistent, 1:
no seizures during monitoring• Six patients had subdural electrode
recording
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
• Surgical morbidity– 1 thalamic infarct (sens loss in thigh)– 1 infection– 2 decline in verbal memory
• Asymptomatic VF deficits in 22 (55%)– Superior quadrantanopsia
• No surgical mortality– 1 death in medical arm (sudden, unexplained)
• Surgical morbidity– 1 thalamic infarct (sens loss in thigh)– 1 infection– 2 decline in verbal memory
• Asymptomatic VF deficits in 22 (55%)– Superior quadrantanopsia
• No surgical mortality– 1 death in medical arm (sudden, unexplained)
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
• Primary outcome (Engle class I)– Surgical group – 58%
• 64% in group actually having surgery– Medical group – 8%
• Quality of life– Significantly higher in surgical group
• Employment and school attendance– Strong trend in data favoring surgery
• Primary outcome (Engle class I)– Surgical group – 58%
• 64% in group actually having surgery– Medical group – 8%
• Quality of life– Significantly higher in surgical group
• Employment and school attendance– Strong trend in data favoring surgery
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
• Engle editorial– “Even if referrals for surgery for epilepsy
increase, successful outcomes with respect to seizures may not have a maximal beneficial effect on patients’ lives until referring physicians stop considering intervention for seizures a last resort.”
• Engle editorial– “Even if referrals for surgery for epilepsy
increase, successful outcomes with respect to seizures may not have a maximal beneficial effect on patients’ lives until referring physicians stop considering intervention for seizures a last resort.”
Wiebe et al NEJM 2001Wiebe et al NEJM 2001
• What is it?• How effective is it?• Is it better or worse than Anterior Temporal
Lobectomy?– Seizure outcome– Neuropsychological outcome– Other
• When should its use be considered?
• What is it?• How effective is it?• Is it better or worse than Anterior Temporal
Lobectomy?– Seizure outcome– Neuropsychological outcome– Other
• When should its use be considered?
AmygdalohippocampectomyAmygdalohippocampectomy
Epilepsy SurgeryEpilepsy Surgery
Why Should AH be Considered?
Why Should AH be Considered?
• Preserve temporal neocortex in well-defined cases of mesial TL epilepsy
• What it is• How effective it is• When its use should be considered• Potential Advantages over Anterior
Temporal Lobectomy
• What it is• How effective it is• When its use should be considered• Potential Advantages over Anterior
Temporal Lobectomy
AmygdalohippocampectomyAmygdalohippocampectomy
Epilepsy SurgeryEpilepsy Surgery
Does Smaller = Better?ATL v AH
Does Smaller = Better?ATL v AH
• What we want:– Large– Randomized– Contemporary– Single Center– Well defined selection criteria and pathology– Comprehensive standardized neuropsychological
battery and outcome measurements
• What we want:– Large– Randomized– Contemporary– Single Center– Well defined selection criteria and pathology– Comprehensive standardized neuropsychological
battery and outcome measurements
• What we have– Variable size– Non-randomized– Non-contemporary– Various inclusion criteria– Varied neuropsychological assessments at
variable time points
• What we have– Variable size– Non-randomized– Non-contemporary– Various inclusion criteria– Varied neuropsychological assessments at
variable time points
Does Smaller = Better?ATL v AH
Does Smaller = Better?ATL v AH
AH vs ATL: Seizure outcomeAH vs ATL: Seizure outcome
• Overall Outcome– 71% Class I– 11% Class II – 82% “satisfactory”
• Predictive factors– Clear MRI lesion– No history of status– MRI suggesting ganglioglioma or DNET– Concordant lateralized memory deficit– Absence of Dysplasia
• Overall Outcome– 71% Class I– 11% Class II – 82% “satisfactory”
• Predictive factors– Clear MRI lesion– No history of status– MRI suggesting ganglioglioma or DNET– Concordant lateralized memory deficit– Absence of Dysplasia
– 17 ATL, 32 AH• Seizure free outcomes equivalent• IQ: Both groups gained 6-7 points postop.• Memory
– ATL: worsened non-verbal memory with R ATL– ATL: much worsened verbal memory with L ATL– AH: better memory following R AH– AH: smaller decrease in VM following L AH
• Non-randomized, non-contemporary• N=49
– 17 ATL, 32 AH• Seizure free outcomes equivalent• IQ: Both groups gained 6-7 points postop.• Memory
– ATL: worsened non-verbal memory with R ATL– ATL: much worsened verbal memory with L ATL– AH: better memory following R AH– AH: smaller decrease in VM following L AH