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OBJECTIVES We designed a prospective, individual-controlled study to evaluate the effect of cardiac-based VNS (cbVNS) in a cohort of patients with generalized epilepsy (GE). MATERIALS AND METHODS Twenty patients were included. They were followed up for six months under regular VNS (rVNS) and subsequently for six months during cbVNS. Stimulation parameters were 500 μsec, 30 Hz, and up to 2.5 mA. Seizure frequency was documented after two, four, and six months during the rVNS and cbVNS phases. Patients with at least 50% seizure frequency reduction were considered responders. The total and relative amount of stimulation cycles generated by both rVNS and cbVNS activation were documented. Findings during rVNS were compared to baseline and cbVNS data were compared to those during rVNS. RESULTS There was a significant decrease in mean seizure frequency (61% [95% CI, 48-74]; p

Background Drug-resistant epilepsy (DRE) affects 7–20% of children with epilepsy. Although some risk factors for DRE have been identified, the results have not been consistent. Moreover, data regarding the risk factors for epilepsy and its seizure outcome in the first 2 years of life are limited. Methods We analyzed data for children aged 0–2 years with epilepsy and neurodevelopmental disability (NDD) from January, 2013, through December, 2017. These patients were followed up to compared the risk of DRE in patients with genetic defect (genetic group) with that without genetic defect (nongenetic group). Additionally, we conducted a meta-analysis to identify the pooled prevalence of genetic factors in children with DRE Results A total of 96 patients were enrolled. A total of 68 patients were enrolled in the nongenetic group, whereas 28 patients were enrolled in the genetic group. The overall DRE risk in the genetic group was 6.5 times (95% confidence interval [CI], 2.15–19.6; p = 0.03) higher than that in the nongenetic group. Separately, a total of 1308 DRE patients were participated in the meta-analysis. The pooled prevalence of these patients with genetic factors was 22.8% (95% CI 17.4–29.3) Conclusions The genetic defect plays a crucial role in the development of DRE in younger children with epilepsy and NDD. The results can serve as a reference for further studies of epilepsy panel design and may also assist in the development of improved treatments and prevention strategies for DRE.

Background Tumors presenting with drug-resistant seizures are termed as long-term epilepsy-associated tumors (LEATs). LEATs are more common in the temporal lobe, occur predominantly in pediatric age, and focal neurological deficits are rare. In this article, we aim to highlight our surgical experience in terms of seizure outcome among LEATs and discuss the factors affecting outcome. Methodology We have retrospectively analyzed all the operated cases of intra-axial brain tumors with seizures (2015–2019). The clinical and radiographic data were collected from the hospital record system. For comparison, 2 groups were made (group 1 with good seizure control, i.e., Engel 1; and group 2 poor seizure outcome, i.e., Engel 2 and 3). Results A total of 51 cases were included; the temporal lobe was the most common location (n = 27); 23 patients had seizure frequency of “more than 1 seizure per week.” Focal unaware seizures/complex partial seizures were the most common type of seizures encountered (n = 28). At a mean follow-up of 39.60 months, 38 patients had Engel 1 (78.5%) outcome (35 cases [71.05%] had the seizure duration of ≤2 years). The median duration of symptoms (group 1, 25 months vs. group 2, 65 months) was significantly different (P = 0.002). On comparing patients with seizure duration, we found a statistically significant difference (P Conclusion A shorter duration of symptoms, younger age of the patient, partial/focal seizures, and gross total excision were predictors of a good seizure outcome. Histopathology of the tumor does not affect the outcome when one compares glioneuronal tumors with non–glioneuronal tumors.

Objective Tumors with seizures as primary mode of presentation are collectively called Long-term epilepsy associated tumors (LEATs or Epileptomas). The overall survival is good so ‘seizure outcome’ becomes the primary goal rather than neuro-oncological outcome. Methods A retrospective analysis of our surgical database (2015−19) was done to find operated patients of intra-axial brain tumors with age less than 25-years and who had presented with seizures. Results The mean age at presentation was 16.44 years (SD + 6.82 years). Complex partial seizures/focal unaware seizures were the most common type of seizures encountered (n = 22) with mean duration of seizures was 49.50 months (SD + 31.04 months). The most common pathology was glioneuronal tumors (GNTs) (n = 17). Gross total resection (GTR) group had a significantly better seizure outcome as compared with the Subtotal resection (STR) group (p = 0.006). Presence of focal or partial seizure was a significant factor pointing towards a better seizure control (p = 0.005). Conclusion The shorter duration of symptoms, partial/focal seizures and gross total excision were predictors of a good seizure-outcome. Age of the patient and the histopathology of the tumor does not affect seizure-outcome on comparing GNTs with non GNTs.

Background High-frequency oscillation (HFO) represents a promising biomarker of epileptogenicity. However, the significant interindividual differences among patients limit its application in clinical practice. Here, we applied and evaluated an individualized, frequency-based approach of HFO analysis in stereoelectroencephalography (SEEG) data for localizing the epileptogenic zones (EZs). Methods Clinical and SEEG data of 19 patients with drug-resistant focal epilepsy were retrospectively analyzed. The individualized spectral power of all signals recorded by electrode array, i.e., the relative strength of HFO, was computed with a wavelet method for each patient. Subsequently, the clinical value of the relative strength of HFO for identifying the EZ was evaluated. Results Focal increase in the relative strength of HFO in SEEG recordings were identified in all 19 patients. HFOs identified inside the clinically identified seizure onset zone had more spectral power than those identified outside (p < 0.001), and HFOs in 250-500 Hz band (fast ripples) seemed to be more specific identifying the EZ than in those in 80-250 Hz band (ripples) (p < 0.01). The resection of brain regions generating HFOs resulted in a favorable seizure outcome in 17 patients (17/19; 89.5%), while in the cases of other patients with poor outcomes, the brain regions generating HFOs were not removed completely. Conclusion The relative strength of HFO, especially fast ripples, is a promising effective biomarker for identifying the EZ and can lead to a favorable seizure outcome if used to guide epilepsy surgery.

International audience; Purpose: This study aims to evaluate the performance of 18 F-FDG PET for distinguishing the epileptogenic zone (EZ) from propagation and non-involved zones at brain area level, as defined using stereo-EEG, in patients with pharmacoresistant epilepsy due to malformations of cortical development (MCD). Additionally, we seek to determine the relationship between 18 F-FDG-PET data and post-surgical seizure outcome. Methods: Thirty-eight patients with MCD were explored with 18 F-FDG PET and stereo-EEG. We compared PET metabolism of each patient to a control-population of healthy subjects. Based on MRI and SEEG, we separated 4 distinct zones at individual level: lesional, epileptogenic non-lesional, propagation, and non-involved. Then, we analysed: 1) difference of PET metabolism within these four distinct zones; 2) performance of PET in defining the EZ within the SEEG-sampled areas; 3) relation between extension of PET hypometabolism and post-surgical seizure outcome. Results: We found: 1) a gradient of PET hypometabolism from non-involved to propagation, then to epileptogenic and lesional zones (p

OBJECTIVE There is an increasing interest in stereo-electroencephalography (SEEG) for invasive evaluation of insular epilepsy. The implantation of insular SEEG electrodes, however, is still challenging due to the anatomical location and complex functional segmentation in both an anteroposterior and ventrodorsal (i.e., superoinferior) direction. While the orthogonal approach (OA) is the shortest trajectory to the insula, it might insufficiently cover these networks. In contrast, the anterior approach (AOA) or posterior oblique approach (POA) has the potential for full insular coverage, with fewer electrodes bearing a risk of being more inaccurate due to the longer trajectory. Here, the authors evaluated the implantation accuracy and the detection of epilepsy-related SEEG activity with AOA and POA insular trajectories. METHODS This retrospective study evaluated the accuracy of 220 SEEG electrodes in 27 patients. Twelve patients underwent a stereotactic frame-based procedure (frame group), and 15 patients underwent a frameless robot-assisted surgery (robot group). In total, 55 insular electrodes were implanted using the AOA or POA considering the insular anteroposterior and ventrodorsal functional organization. The entry point error (EPE) and target point error (TPE) were related to the implantation technique (frame vs robot), the length of the trajectory, and the location of the target (insular vs noninsular). Finally, the spatial distribution of epilepsy-related SEEG activity within the insula is described. RESULTS There were no significant differences in EPE (mean 0.9 ± 0.6 for the nonsinsular electrodes and 1.1 ± 0.7 mm for the insular electrodes) and TPE (1.5 ± 0.8 and 1.6 ± 0.9 mm, respectively), although the length of trajectories differed significantly (34.1 ± 10.9 and 70.1 ± 9.0 mm, repsectively). There was a significantly larger EPE in the frame group than in the robot group (1.5 ± 0.6 vs 0.7 ± 0.5 mm). However, there was no group difference in the TPE (1.5 ± 0.8 vs 1.6 ± 0.8 mm). Epilepsy-related SEEG activity was detected in 42% (23/55) of the insular electrodes. Spatial distribution of this activity showed a clustering in both anteroposterior and ventrodorsal directions. In purely insular onset cases, subsequent insular lesionectomy resulted in a good seizure outcome. CONCLUSIONS The implantation of insular electrodes via the AOA or POA is safe and efficient for SEEG implantation covering both anteroposterior and ventrodorsal functional organization with few electrodes. In this series, there was no decrease in accuracy due to the longer trajectory of insular SEEG electrodes in comparison with noninsular SEEG electrodes. The results of frame-based and robot-assisted implantations were comparable.

Purpose Vagus nerve stimulation (VNS) is a palliative treatment for intractable epilepsy. While the expected outcome of VNS is well known, the clinical predictors of outcome are not clearly defined. We investigated the predictors and seizure reduction rates of VNS in pediatric patients. Methods We retrospectively reviewed medical records, radiological data, EEG, and clinical outcomes of 47 pediatric patients who underwent VNS implantation in our institution. Chi-squared tests and Fisher’s exact tests were used for categorical variables, and Student’s t test was applied for continuous variables. A paired T test was used for the comparison of pre- and post-insertion for each variable. Results The mean age at the time of VNS surgery was 14.7 years (range, 5–26 years). The mean interval from seizure onset to surgery was 8.3 years (range, 2–16 years). Responders (≥50% reduction in seizure frequency) included 22 patients (47%) at six months postoperatively and 25 patients (53%) at one year postoperatively. The overall mean seizure frequency was reduced from 8.0 per week to 5.1 per week 12 months after implantation (36%, p=0.006). Patients with focal onset epilepsy on electroencephalography (EEG) had 7.5 seizures per week preoperatively, which was reduced to 5.1 seizures per week postoperatively (32%, p=0.009). Patients who did not undergo resection surgery prior to VNS insertion had a reduction rate of 43% (p=0.006). Conclusions Pediatric patients with intractable epilepsy who have focal lesions in eloquent areas or unmatched ictal zones on EEG with multifocal lesions could be good candidates for VNS.

Highlights • Inpatient VEEG study is the gold standard in patients with TLE undergoing presurgical evaluation. • VEEG is expensive and not available for a significant proportion of patients in developing countries. • AmbEEG may be used instead of VEEG to identify candidates for temporal lobectomy in selected patients with refractory TLE and concordant semiology, unilateral EEG, neuroimaging and neuropsychological data., Purpose Inpatient Video EEG Monitoring (VEM) is the typical study performed in presurgical evaluations. It is expensive and not widely available in developing countries. Recent studies suggested that in selected patients with mesial temporal lobe epilepsy secondary to unilateral mesial temporal sclerosis (MTS), the recording of unilateral interictal epileptiform activity ipsilateral to the MTS may yield sufficient presurgical EEG data. Outpatient prolonged ambulatory EEG (AEEG) could be an alternative in these cases. The purpose of this study was to compare the post-surgical seizure outcome and costs between patients evaluated with AEEG versus VEM. Methods Thirty patients with TLE were included: 21 evaluated with VEM and 9 with AmbEEG and underwent surgery between 2011 and 2017. The minimum, post-surgical follow-up period was 1 year. Results Seven of nine patients who underwent AEEG had seizures ipsilateral to MTS. In two patients only unilateral interictal activity ipsilateral to the lesion was recorded. All patients were free of disabling seizures (Engel Class I) at last follow-up. The mean cost per patient of AEEG was $980 and was $4680 for VEM. Conclusion AEEG may be used to identify candidates for temporal lobectomy in selected patients with unilateral lesional mesial TLE. This approach to EEG monitoring could make epilpesy surgery more affordable to some patients in developing countries.

Background Surgery is a widely accepted treatment option for drug-resistant focal epilepsy. A detailed analysis of longitudinal postoperative seizure outcomes and use of antiepileptic drugs for different brain lesions causing epilepsy is not available. We aimed to analyse the association between histopathology and seizure outcome and drug freedom up to 5 years after epilepsy surgery, to improve presurgical decision making and counselling.Methods In this retrospective, multicentre, longitudinal, cohort study, patients who had epilepsy surgery between Jan 1, 2000, and Dec 31, 2012, at 37 collaborating tertiary referral centres across 18 European countries of the European Epilepsy Brain Bank consortium were assessed. We included patients of all ages with histopathology available after epilepsy surgery. Histopathological diagnoses and a minimal dataset of clinical variables were collected from existing local databases and patient records. The primary outcomes were freedom from disabling seizures (Engel class 1) and drug freedom at 1, 2, and 5 years after surgery. Proportions of individuals who were Engel class 1 and drug-free were reported for the 11 main categories of histopathological diagnosis. We analysed the association between histopathology, duration of epilepsy, and age at surgery, and the primary outcomes using random effects multivariable logistic regression to control for confounding.Findings 9147 patients were included, of whom seizure outcomes were available for 8191 (89.5%) participants at 2 years, and for 5577 (61.0%) at 5 years. The diagnoses of low-grade epilepsy associated neuroepithelial tumour (LEAT), vascular malformation, and hippocampal sclerosis had the best seizure outcome at 2 years after surgery, with 77.5% (1027 of 1325) of patients free from disabling seizures for LEAT, 74.0% (328 of 443) for vascular malformation, and 71.5% (2108 of 2948) for hippocampal sderosis. The worst seizure outcomes at 2 years were seen for patients with focal cortical dysplasia type I or mild malformation of cortical development (50.0%, 213 of 426 free from disabling seizures), those with malformation of cortical development-other (52.3%, 212 of 405 free from disabling seizures), and for those with no histopathological lesion (53.5%, 396 of 740 free from disabling seizures). The proportion of patients being both Engel class 1 and drug-free was 0-14% at 1 year and increased to 14-51% at 5 years. Children were more often drug-free; temporal lobe surgeries had the best seizure outcomes; and a longer duration of epilepsy was associated with reduced chance of favourable seizure outcomes and drug freedom. This effect of duration was evident for all lesions, except for hippocampal sclerosis.Interpretation Histopathological diagnosis, age at surgery, and duration of epilepsy are important prognostic factors for outcomes of epilepsy surgery. In every patient with refractory focal epilepsy presumed to be lesional, evaluation for surgery should be considered. Copyright (C) 2020 Elsevier Ltd. All rights reserved.

Hemispherectomy was primarily introduced for the treatment of malignant gliomas. Early experience with this procedure showed beneficial effects on seizures. Thus, already from the 1950s on, hemispherectomy has been recognized as a valuable tool for the surgical treatment of a subgroup of epileptic patients who show a diffuse pathology affecting one hemisphere which coincides with infantile hemiplegia. Hemispherical procedures have been improved over decades, all aiming at the best seizure control with the lowest morbidity. All techniques available follow common principles: disruption of the descending and ascending fibers through the corona radiata and internal capsule, removal of the mesial temporal structures, and callosotomy. Resective procedures include anatomical hemispherectomy and hemidecortication/hemicorticectomy. Disconnective strategies comprise transsylvian and vertical hemispherotomy. Combined resective/disconnective approaches include Rasmussen’s functional hemispherectomy and its modifications. Today, anatomical hemispherectomy and hemidecortication/hemicorticectomy have been largely abandoned. The transsylvian-transventricular key-hole approach is ideal for atrophic hemispheres and enlarged ventricles. Modified Rasmussen’s techniques are suitable for patients with atrophic, normal, and enlarged hemispheres. Vertical hemispherotomy constitutes a good alternative to combined resective and disconnective strategies that works well in almost all conditions. The value of resection of the insula is still unproven. It should be emphasized that the choice of the surgical approach within the limits given by different techniques and the patient’s situation depends to major parts on the individual training and experience of the surgeon. Systematic reviews and meta-analyses consistently demonstrate seizure-free (Engel I) outcome in around 70% of patients with best results achieved with acquired pathologies and Sturge–Weber syndrome mainly causing hemiatrophy, while seizure outcome with developmental pathologies, in particular hemimegalencephaly, is less favorable.

Based on clinical studies with cortical recordings by Penfield and Jasper at the Montreal Neurological Institute (MNI) indicating temporal spike foci in a high number of epilepsy cases, temporal lobe resections for epilepsy have been started. Nowadays, the syndrome of mesial temporal lobe epilepsy (MTLE) constitutes a well-known entity accounting for 90–95% of temporal lobe epilepsies. Seizure freedom rates reported mainly range between 40% and 70% and marked reduction of seizure frequency between 60% and 90%. Left-sided resections seem to be critical leading to decline in verbal memory in a significant portion of patients. An extensive body of literature is available on different temporal approaches including modifications of lateral and mesial resection strategies, all aiming at the ideal combination of maximal seizure freedom and minimal cognitive impairment. Starting with anterior temporal lobectomy (ATL) in the 1950s, a tendency has been witnessed over the decades to reduce the extent of lateral resection in MTLE based on the hypothesis that smaller resections lead to the same favorable seizure outcome as ATL, but provide better cognitive function. Similarly, the extent of mesial resection has been modified hypothesizing that shorter mesial resections are advantageous with respect to the cognitive outcome while providing similar favorable seizure outcome as compared to larger mesial resections. According to the data available, it seems that these hypotheses cannot be maintained longer. While smaller lateral and shorter mesial resections have been shown to provide the same favorable results in terms of seizure outcome as compared to larger resections, no significant differences in cognitive outcome between more extended and more restricted lateral and mesial resections have been proven. Therefore, the surgeon should choose the approach according to his/her individual experience starting with ATL.

Background: Identifying the predictors for seizure outcome in autoimmune encephalitis (AE) and investigating how to prevent persistent seizures would have major clinical benefits effectively. Thus, we aimed to perform a systematic review and meta-analysis to examine seizure outcome-related factors in AE patients., Methods: PubMed and EMBASE were systematically searched from inception to 10 June 2022 for studies investigating seizure outcome-related factors in AE. The pooled effect estimates, including standardized mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals (CIs), were calculated to estimate the effect of each included factor on the seizure outcome., Results: A total of 10 studies were included in the meta-analysis. Our pooled results of this meta-analysis showed that five factors were found to increase the risk of persistent seizures in AE patients, including onset with seizures (OR = 2.106, 95% CI = 1.262-3.514, p = 0.004), status epilepticus (OR = 3.017, 95% CI = 1.995-4.563, p < 0.001), EEG abnormalities (OR = 1.581, 95% CI = 1.016-2.46, p = 0.042), MRI abnormalities (OR = 1.554, 95% CI = 1.044-2.283, p = 0.03), and longer time from clinical onset to immunotherapy (SMD = 1.887, 95% CI = 0.598-3.156, p = 0.004)., Conclusion: Our meta-analysis indicated that onset with seizures, status epilepticus, EEG abnormalities, MRI abnormalities, and longer time from clinical onset to immunotherapy were risk factors for persistent seizures in AE patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Luo, Zhong, Chen and Lin.)

Aim: To examine the developmental and seizure outcomes after corpus callosotomy (CC) in early childhood.Methods: We retrospectively identified 106 patients who underwent CC for drug-resistant epilepsy before the age of 6 years, at the Nagasaki Medical Center, between July 2002 and July 2016. Patients’ developmental outcomes were evaluated one year after CC using the Kinder Infant Development Scale.Results: The mean preoperative developmental quotient (DQ) was 25.0 (standard deviation [SD], 20.8), and the mean difference between preoperative DQ and one-year postoperative DQ was −1.6 points (SD, 11.6). However, 42.5% of patients had a mean DQ increase of 6.5 points (SD, 6.4), one year after CC from that before surgery. Factors related to the improvement in postoperative DQ were ‘low preoperative DQ’, ‘developmental gain 1 month postoperatively’, and ‘postoperative seizure-free state’. Approximately 21.7% of patients were seizure-free 1 year after CC.Interpretation: Performing CC, in infancy and early childhood for patients with drug-resistant epilepsy and severe developmental impairment, was associated with improved development in 42.5% of patients. Remission of seizures, even if only for a short period, contributed to developmental improvement. From a developmental perspective, CC for drug-resistant epilepsy in early childhood is an effective treatment., 長崎大学学位論文 学位記番号:博(医歯薬)甲第1444号 学位授与年月日:令和4年3月18日, Author: Ryoko Honda, Hiroshi Baba, Kohei Adachi, Rika Koshimoto, Tomonori Ono, Keisuke Toda, Shigeki Tanaka, Shiro Baba, Kazumi Yamasaki, Hiroshi Yatsuhashi, Citation: Epilepsy & Behavior, 117, art. no. 107799; 2021

OBJECTIVE: We aimed to determine the rates and predictors of resection and seizure freedom after bilateral stereo-electroencephalography (SEEG) implantation. METHODS: We reviewed 184 patients who underwent bilateral SEEG implantation (2009-2015). Noninvasive and invasive evaluation findings were collected. Outcomes of interest included subsequent resection and seizure freedom. Statistical analyses employed multivariable logistic regression and proportional hazard modeling. Preoperative and postoperative seizure frequency, severity, and quality of life scales were also compared. RESULTS: Following bilateral SEEG implantation, 106 of 184 patients (58%) underwent resection. Single seizure type (P = 0.007), a family history of epilepsy (P = 0.003), 10 or more seizures per month (P = 0.004), lower number of electrodes (P = 0.02), or sentinel electrode placement (P = 0.04) was predictive of undergoing a resection, as were lack of nonlocalized (P < 0.0001) or bilateral (P < 0.0001) ictal-onset zones on SEEG. Twenty-six of 81 patients (32% with follow-up greater than 1 year) remained seizure-free. Predictors of seizure freedom were single seizure type (P = 0.01), short epilepsy duration (P = 0.008), use of 2 or fewer antiepileptic drugs (AEDs) at the time of surgery (P = 0.0006), primary localization hypothesis involving the frontal lobe (P = 0.002), sentinel electrode placement only (P = 0.02), and lack of overlap between ictal-onset zone and eloquent cortex (P = 0.04), along with epilepsy substrate histopathology (P = 0.007). Complete resection of a suspected focal cortical dysplasia showed a trend to increased likelihood of seizure freedom (P = 0.09). The 44 of 55 patients (80%) who underwent resection and experienced seizure recurrence had >50% seizure reduction, as opposed to 26 of 45 patients (58%) who continued medical therapy alone (P = 0.003). Seventy-two percent of patients had a clinically meaningful quality of life improvement (>10% decrease in the Quality of Life in Epilepsy [QOLIE-10] score) at 1 year. SIGNIFICANCE: A strong preimplantation hypothesis of a suspected unifocal epilepsy increases the odds of resection and seizure freedom. We discuss a tailored approach, taking into account localization hypothesis and suspected epilepsy etiology in guiding implantation and subsequent surgical strategy.

Objective: The European Union–funded E-PILEPSY network (now continuing within the European Reference Network for rare and complex epilepsies [EpiCARE]) aims to harmonize and optimize presurgical diagnostic procedures by creating and implementing evidence-based guidelines across Europe. The present study evaluates the current evidence on the diagnostic accuracy of long-term video-electroencephalographic monitoring (LTM) in identifying the epileptogenic zone in epilepsy surgery candidates. Methods: MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched for relevant articles. First, we used random-effects meta-analytical models to calculate pooled estimates of sensitivity and specificity with respect to postsurgical seizure freedom. In a second phase, we analyzed individual patient data in an exploratory fashion, assessing diagnostic accuracy within lesional and nonlesional temporal lobe epilepsy (TLE) and extratemporal lobe epilepsy (ETLE) patients. We also evaluated seizure freedom rate in the presence of “localizing” or “nonlocalizing” LTM within each group. The quality of evidence was assessed using the QUADAS-2 tool and the GRADE approach. Results: Ninety-four studies were eligible. Forty-four were included in sensitivity meta-analysis and 34 in specificity meta-analysis. Pooled sensitivity was 0.70 (95% confidence interval [CI] = 0.60-0.80) and specificity was 0.40 (95% CI = 0.27-0.54). Subgroup analysis was based on individual data of 534 patients (41% men). In lesional TLE patients, sensitivity was 0.85 (95% CI = 0.81-0.89) and specificity was −0.19 (95% CI = 0.13-0.28). In lesional ETLE patients, a sensitivity of 0.47 (95% CI = 0.36-0.58) and specificity of 0.35 (95% CI = 0.21-0.53) were observed. In lesional TLE, if LTM was localizing and concordant with resection site, the seizure freedom rate was 247 of 333 (74%), whereas in lesional ETLE it was 34 of 56 (61%). The quality of evidence was assigned as “very low.”. Significance: Long-term video-electroencephalographic monitoring is associated with moderate sensitivity and low specificity in identification of the epileptogenic zone. Sensitivity is remarkably higher in lesional TLE compared to lesional ETLE. Substantial heterogeneity across the studies indicates the need for improved design and quality of reporting.

Purpose The success of epilepsy surgery lies in identifying the ictal onset zone accurately. The significance of auras has little been explored on surgical outcome in drug-resistant epilepsy. This study focuses on the clinicopathological correlation of aura(s) and its role in predicting surgical outcome in drug-resistant temporal lobe epilepsy (TLE). We compared surgical outcome in TLE between patients with and without aura and identified the clinico-pathological, radiological and surgical differences between the two groups. Methods Consecutive patients who underwent presurgical evaluation from January 2009 to December 2014 for drug-resistant TLE who underwent anterior temporal lobectomy (ATL) were included. Patients were followed up at 3months, 12 months and then annually. Results Among 456 patients, 344(75%) had aura. Multivariate logistic regression showed that prototype EEG pattern at ictal onset (OR 2.12, 95% CI 1.18–3.06, p = 0.012) and right sided epileptogenic zone (OR 1.82 95% CI 1.18–3.78, p = 0.007) were significantly associated with presence of aura. There was no difference in surgical outcome between those with and without aura. But patients with auditory aura (OR 7.28, CI 2.80–18.95, p = 0.0002) and vertiginous aura (OR 3.01, CI 1.55–7.85, p = 0.028) had a poor surgical outcome. Bivariate analysis showed that normal MRI (p = 0.028) and normal/indeterminate pathology (p = 0.001) were significantly more common with auditory/vertiginous auras. Conclusions Mere presence of aura does not affect outcome after TLE surgery. However, auditory and vertiginous auras are predictors of poor surgical outcome. These patients require more extensive screening for an ictal onset zone beyond standard limits of ATL before surgery.

Purpose Focal cortical dysplasia (FCD) is the major cause of focal intractable epilepsy in childhood. Here we analyze the factors influencing the success of surgical treatment in a large cohort of children with histologically ascertained FCD. Method A retrospective study of the effects of FCD type, surgical intervention, and age at surgery in a pediatric cohort. Results A total of 113 patients (71 male; mean age at surgery 10.3 years; range 0–18) were analyzed; 45 had undergone lesionectomy, 42 lobectomy, 18 multi-lobectomy, and eight hemispherotomy. Complete seizure control (Engel Ia) was achieved in 56% after two years, 52% at five years, and 50% at last follow-up (18–204 months). Resections were more extensive in younger patients (40% of the surgeries affecting more than one lobe in patients aged nine years or younger vs. 22% in patients older than nine years). While resections were more limited in older children, their long-term outcome tended to be superior (42% seizure freedom in patients aged nine years or younger vs. 56% in patients older than nine years). The outcome in FCD I was not significantly inferior to that in FCD II. Conclusions Our data confirm the long-term efficacy of surgery in children with FCD and epilepsy. An earlier age at surgery within this cohort did not predict a better long-term outcome, but it involved less-tailored surgical approaches. The data suggest that in patients with an unclear extent of the dysplastic area, later resections may offer advantages in terms of the precision of surgical-resection planning.

Objective To evaluate the prognostic value of postoperative EEGs to estimate post anterior temporal lobectomy (ATL) seizure outcome. Methods We studied postoperative EEGs in 325 consecutive patients who had minimum five years of post-ATL followup. Interictal epileptiform discharges (IEDs) present only during sleep were classified as sleep IEDs. We defined favorable final-year outcome as no seizures during the final one year and favorable absolute-postoperative outcome as no seizures during the entire postoperative period. Results At mean follow-up of 7.3 ± 1.8 years, 281 (86.5%) patients had favorable final-year outcome while 161 (49.5%) had favorable absolute-postoperative outcome. IEDs on three months and one year EEG were associated with unfavorable outcomes while IEDs at 7th day had no association with outcomes. Sleep record increased the yield of IEDs by 30% at each time-point without compromising predictive value. EEG at one year predicted the risk of seizure recurrence on drug withdrawal. Conclusion While EEG at three months and at one-year after ATL predicted seizure outcome, EEG at 7th day was not helpful. Sleep record increases the sensitivity of postoperative EEG without compromising specificity. Significance Both awake and sleep EEG provide useful information in postoperative period following ATL.

Objectives: The resection of an epileptic focus provides a chance for seizure outcome regression, which markedly influences the level of patients' quality of life. One of its dimensions is the satisfaction with one's sexual life. Patients with epilepsy usually report low sexual satisfaction due to commonly diagnosed disturbances of sexual functions characterized by a multifactorial etiology. The aim of the study was to assess the level of satisfaction with their sexual life in patients after the surgical resection of an epileptic focus. Patients and methods: The study group included 63 patients who had undergone the surgical resection of an epileptic focus in a neurosurgical ward. The study was conducted with the present authors' own tool consisting of three parts. Result: The patients assessed their sexual life as moderately satisfactory (the average score was 4 out of a 7-grade scale). 38% of the respondents reported a complete withdrawal from sexual life, sporadic sexual activity or masturbatory behavior (instead of interactive behavior). This type of behavior correlates with the reduction in sexual satisfaction. Higher satisfaction is associated with initiating new behavior which is adequate to the patient's health status, more frequent sexual contacts or no changes between behavior before and after the surgery. Moreover, the removal of an epileptic focus reduced the fear of a possible seizure during intercourse. Conclusion: Based on the findings it may be assumed that the sexual satisfaction of patients with epilepsy after the resection of an epileptogenic focus is markedly affected by psychological factors, which should be considered in the therapeutic process. Keywords: Epilepsy, Sexual satisfaction, Epileptic focus resection, Quality of life

OBJECTIVEThe aim of this study was to present long-term seizure outcome data in a consecutive series of patients with refractory mesial temporal lobe epilepsy primarily treated with transsylvian selective amygdalohippocampectomy (SAHE).METHODSThe authors retrospectively analyzed prospectively collected data for all patients who had undergone resective surgery for medically refractory epilepsy at their institution between July 1994 and December 2014. Seizure outcome was assessed according to the International League Against Epilepsy (ILAE) and the Engel classifications.RESULTSThe authors performed an SAHE in 158 patients (78 males, 80 females; 73 right side, 85 left side) with a mean age of 37.1 ± 10.0 years at surgery. Four patients lost to follow-up and 1 patient who committed suicide were excluded from analysis. The mean follow-up period was 9.7 years. At the last available follow-up (or before reoperation), 68 patients (44.4%) had achieved an outcome classified as ILAE Class 1a, 46 patients (30.1%) Class 1, 6 patients (3.9%) Class 2, 16 patients (10.4%) Class 3, 15 patients (9.8%) Class 4, and 2 patients (1.3%) Class 5. These outcomes correspond to Engel Class I in 78.4% of the patients, Engel Class II in 10.5%, Engel Class III in 8.5%, and Engel Class IV in 2.0%. Eleven patients underwent a second surgery (anterior temporal lobectomy) after a mean of 4.4 years from the SAHE (left side in 6 patients, right side in 5). Eight (72.7%) of these 11 patients achieved seizure freedom.The overall ILEA seizure outcome since (re)operation after a mean follow-up of 10.0 years was Class 1a in 72 patients (47.0%), Class 1 in 50 patients (32.6%), Class 2 in 7 patients (4.6%), Class 3 in 15 patients (9.8%), Class 4 in 8 patients (5.2%), and Class 5 in 1 patient (0.6%). These outcomes correspond to an Engel Class I outcome in 84.3% of the patients.CONCLUSIONSA satisfactory long-term seizure outcome following transsylvian SAHE was demonstrated in a selected group of patients with refractory temporal lobe epilepsy.

Background Epilepsy surgery is well established as safe and successful for children with temporal lobe epilepsy (TLE). Despite evidence from available data, there remains some reluctance to refer children with medically refractory epilepsy for preoperative evaluation and workup for possible surgery. Objective To present the largest case series of pediatric (TLE) patients thus far, in order to better understand the predictability of preoperative evaluation on seizure outcome, and to better understand longitudinal outcomes in a large pediatric cohort. Methods One hundred eighty-three pediatric patients with TLE who underwent surgical treatment between 1988 and 2012 were retrospectively reviewed. Preoperative seizure history, noninvasive and invasive preoperative evaluation, surgical results, pathological results, long-term seizure outcomes, and complications were evaluated. A review of pediatric TLE in the literature was also undertaken to better understand reported complications and long-term outcomes. Results Mean follow-up was 42 mo (range 12-152 mo); 155 patients had good seizure outcomes (Engel I/II; 84.8%) and 28 patients had poor seizure outcomes (Engel III/IV; 15.2%); 145 patients were Engel I (78.8%). Only 10 patients did not have worthwhile improvement (Engel class IV; 5.4%). A review of the literature identified 2089 unique cases of pediatric TLE. Satisfactory seizure outcomes occurred in 1629 patients (79%) with unsatisfactory outcomes in 433 patients (21%). Conclusion Pediatric patients benefit from surgery for medically refractory TLE with an acceptable safety profile regardless of histopathological diagnosis, seizure frequency, or seizure type. Seizure freedom appears to have extensive durability in a significant proportion of surgically treated patients.

Due to a limited number of patients with drug-resistant parietal lobe epilepsy in surgical series, there are insufficient data about long-term seizure outcome following surgery restricted to the parietal lobe. We performed a meta-analysis to asses long-term outcomes in patients with parietal lobe epilepsy who underwent surgery confined to the parietal lobe or resection with major involvement of the parietal cortex. An English language literature search for studies on parietal lobe surgery and outcome was conducted using the MEDLINE database, followed by a manual search based on specific criteria. An inverse variance random effect meta-analysis model was used to estimate the pooled proportion of Engel Class I. Meta-regression models were used to examine the association between outcome and potential predictors. The search yielded seven retrospective studies with a total sample size of 253 patients (mean follow-up: 104.9±74.8 months). Following surgery, Engel Class I surgical outcome was achieved in 62.4% (95% CI: 0.492-0.755). Two independent predictors were identified for positive long-term outcome: interictal EEG localized to the parietal region (p=0.007) and the presence of tumour (p=0.022). Following surgery confined to the parietal lobe or resection with major involvement of the parietal cortex, the long-term prognosis of patients with parietal lobe epilepsy is favourable.

Objective Epileptic spasms (ES) often become drug-resistant. To reveal the electrophysiological difference between children with ES (ES+) and without ES (ES-), we compared the occurrence rate (OR) of high-frequency oscillations (HFOs) and the modulation index (MI) of coupling between slow and fast oscillations. In ES+, we hypothesized that (1) pathological HFOs are more widely distributed and (2) slow oscillations show stronger coupling with pathological HFOs than in ES-. Methods We retrospectively reviewed 24 children with drug-resistant multilobar onset epilepsy, who underwent intracranial video electroencephalography prior to multilobar resections. We measured the OR of HFOs and determined the electrodes with a high rate of HFOs by cluster analysis. We calculated MI, which reflects the degree of coupling between HFO (ripple/fast ripple [FR]) amplitude and 5 different frequency bands of delta and theta activities (0.5-1 Hz, 1-2 Hz, 2-3 Hz, 3-4 Hz, 4-8 Hz). Results In ES+ (n = 10), the OR(FRs) , the number of electrodes with high-rate FRs, and the MI(FRs & 3-4 Hz) in all electrodes were significantly higher than in ES- (n = 14). In both the ES+ and ES- groups, MI(ripples/FRs & 3-4 Hz) was the highest among the 5 frequency bands. Within the good seizure outcome group, the OR(FRs) and the MI(FRs & 3-4 Hz) in the resected area in ES+ were significantly higher than in ES- (OR[FRs] , P = .04; MI[FRs & 3-4 Hz] , P = .04). Significance In ES+, the larger number of high-rate FR electrodes indicates more widespread epileptogenicity than in ES-. High values of OR(FRs) and MI(FRs & 3-4 Hz) in ES+ compared to ES- are a signature of the severity of epileptogenicity. We proved that ES+ children who achieved seizure freedom following multilobar resections exhibited strong coupling between slow oscillations and FRs.

Vagus nerve stimulation (VNS) is a low-risk surgical option for patients with drug resistant epilepsy, although it is impossible to predict which patients may respond to VNS treatment. Resting-state magnetoencephalography (rs-MEG) connectivity analysis has been increasingly utilized to investigate the impact of epilepsy on brain networks and identify alteration of these networks after different treatments; however, there is no study to date utilizing this modality to predict the efficacy of VNS treatment. We investigated whether the rs-MEG network topology before VNS implantation can be used to predict efficacy of VNS treatment. Twenty-three patients with epilepsy who had MEG before VNS implantation were included in this study. We also included 89 healthy control subjects from the Human Connectome Project. Using the phase-locking value in the theta, alpha, and beta frequency bands as a measure of rs-MEG functional connectivity, we calculated three global graph measures: modularity, transitivity, and characteristic path length (CPL). Our results revealed that the rs-MEG graph measures were significantly heritable and had an overall good test-retest reliability, and thus these measures may be used as potential biomarkers of the network topology. We found that the modularity and transitivity in VNS responders were significantly larger and smaller, respectively, than those observed in VNS non-responders. We also observed that the modularity and transitivity in three frequency bands and CPL in delta and beta bands were significantly different in controls than those found in responders or non-responders, although the values of the graph measures in controls were closer to those of responders than non-responders. We used the modularity and transitivity as input features of a naïve Bayes classifier, and achieved an accuracy of 87% in classification of non-responders, responders, and controls. The results of this study revealed that MEG-based graph measures are reliable biomarkers, and that these measures may be used to predict seizure outcome of VNS treatment, Highlights • We investigated whether rs-MEG network topology can predict efficacy of VNS treatment • We calculated graph measures based on PLV as a measure of rs-MEG functional connectivity • The graph measures were significantly heritable and had an overall good test-retest reliability • The modularity and transitivity were significantly different in responders versus non-responders • We achieved an accuracy of 87% in classification of non-responders, responders, and controls • Modularity and transitivity of rs-MEG may be used as clinical biomarkers for prediction of VNS outcome