Epilepsia, 52(8):15221526, 2011

doi: 10.1111/j.1528-1167.2011.03192.x

FULL-LENGTH ORIGINAL RESEARCH

A population-based study of long-term outcome

of epilepsy in childhood with a focal or hemispheric
lesion on neuroimaging
Radhika Dhamija, Brian D. Moseley, Gregory D. Cascino, and Elaine C. Wirrell
Department of Neurology, Mayo Clinic, Rochester, Minnesota, U.S.A.

SUMMARY
Purpose: To evaluate long-term seizure outcome in children with epilepsy and a focal or hemispheric neuroimaging abnormality.
Methods: All children (<18 years and residing in Olmsted
County, Minnesota) with new-onset epilepsy diagnosed
between 1980 and 2004 and a single focal lesion on neuroimaging were identified by review of the Rochester Epidemiologic Project database. Outcomes were divided
into three categories: (1) seizure freedom for 1 or more
years at last follow-up, (2) ongoing seizures but not medically intractable epilepsy, and (3) medically intractable
epilepsy or undergoing epilepsy surgery. We also evaluated the proportion who achieved seizure control without
surgical intervention and whether lesion type predicted
intractability.
Key Findings: Of the 359 children with newly diagnosed
epilepsy, 37 (10%) had a focal or hemispheric lesion on
neuroimaging. Median age of diagnosis was 89 months
(25th percentile 26 months, 75th percentile 142 months)
and at follow-up was 137 months (25th percentile
95 months, 75th percentile 211 months). Eighty-three
percent of children with malformations of cortical

Epilepsy is one of the most frequent neurologic disorders

affecting the pediatric population. Advances in neuroimaging have made a major impact in the evaluation and
management of patients with focal-onset seizures, with
high-resolution magnetic resonance imaging (MRI) showing a structural abnormality in a significant number of
patients previously labeled as cryptogenic (Von Oertzen
et al., 2002; Goyal et al., 2004). The most common potentially resectable lesions detected on neuroimaging in
children with epilepsy include malformations of cortical
Accepted June 8, 2011; Early View publication July 18, 2011.
Address correspondence to Elaine Wirrell, MD, Department of Pediatric
Neurology, Mayo Building, 16th floor, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905, U.S.A. E-mail: wirrell.elaine@mayo.edu
Wiley Periodicals, Inc.
2011 International League Against Epilepsy

development, 67% with mesial temporal sclerosis, 33%

with encephalomalacia, and 50% with vascular malformations had intractable epilepsy at follow-up or underwent
resective surgery for medically intractable epilepsy.
Among the different etiologies, presence of encephalomalacia predicted the lowest likelihood of medical intractability or undergoing surgery (p < 0.01). At final followup, 24 (65%) of our entire cohort was seizure free. Following surgery, seizure freedom was achieved in 80% with
mesial temporal sclerosis, 67% with encephalomalacia,
67% with vascular malformation, and 50% with malformations of cortical development. There was no statistically
significant difference between the different etiologies on
neuroimaging and seizure freedom after surgery. Twelve
children (32%) achieved seizure freedom with medical
management alone.
Significance: Focal lesions on neuroimaging confer a high
risk of medical intractability among children with newonset epilepsy. However, 32% of this cohort achieved
seizure remission with medical management alone,
including 58% with encephalomalacia and 33% with mesial
temporal sclerosis.
KEY WORDS: Epilepsy, Focal lesion, Outcome, Population-based study.

development, focal encephalomalacia or gliosis, mesial

temporal lobe sclerosis, tumors, and vascular malformations
(Woermann & Vollmar, 2009).
Although many children achieve seizure control with
medication, approximately 1040% have medically intractable epilepsy (Camfield et al., 1993; Hauser et al., 1998;
Kwan & Brodie, 2000; Berg et al., 2001; Dlugos et al.,
2001). Such patients may benefit from surgical resection,
with seizure freedom in 6080% with unilateral mesial
temporal lobe epilepsy or tumors and in 4070% with
malformations of cortical development or dual pathology
(Sisodiya, 2000; Dlugos et al., 2001; Wieser et al., 2003;
Nakase et al., 2007; Spencer & Huh, 2008; Roper, 2009).
Surgical series and hospital-based studies have reported
that focal lesions on neuroimaging correlate with high rates
of intractability. However, such studies are biased toward

1522

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Outcome of Epilepsy in Childhood with Focal Lesion on Neuroimaging
selecting patients who have poorly controlled seizures (Semah & Ryvlin, 2005). No study has assessed long-term outcome in a population-based cohort of children documented
to have a focal lesion on neuroimaging at initial diagnosis of
epilepsy. One prospective study in patients seen at a single
epilepsy center examined the success of medical therapy
alone in patients with localization-related epilepsy and
found that the nature of lesion predicted control. The poorest
control was seen with mesial temporal sclerosis (42%) followed by malformations of cortical development (54%),
tumor (63%), infarct (67%), and vascular malformation
(78%) (Stephen et al., 2001). In another hospital-based
observational study of adults, Semah et al. (1998) also
found mesial temporal sclerosis to be a poor prognostic
factor.
The aim of this population-based, retrospective study was
to evaluate what proportion of children with epilepsy and a
potentially resectable lesion on neuroimaging (focal or
hemispheric) achieved seizure control without surgical
intervention and whether lesion type predicted intractability.

Methods
Case identification
Cases were ascertained by screening of the complete
diagnostic indexes of the Rochester Epidemiology Project.
These indexes include inpatient diagnoses, as well as diagnoses at the time of outpatient and emergency room visits at
all medical care facilities in Olmsted County, MN. All
charts were screened using a diagnostic rubric, which
included all seizure and convulsion diagnosis codes, and all
identified charts were reviewed by a pediatric epileptologist. We identified all children aged 1 month through
17 years with new-onset epilepsy diagnosed while residing
in Olmsted County, Minnesota, between 1980 and 2004.
Epilepsy was defined as a predisposition to unprovoked
seizures (Fisher et al., 2005). Most subjects had two or more
unprovoked seizures. However, patients with a single
unprovoked seizure who had evidence of an enduring alteration of the brain that increases the likelihood of further seizures (Fisher et al., 2005), and who were commenced on
antiepileptic drug treatment, were also included. An abnormal neurodevelopmental examination, focal abnormality on
brain imaging, initial presentation in status epilepticus, or
specific EEG findings (epileptiform discharge, intermittent
rhythmic focal delta activity) were considered indicative of
an enduring alteration of the brain that increases the likelihood of further seizures. Patients who were treated after a
single seizure, but who lacked any of the preceding features
were excluded. We included children who had two afebrile
seizures occurring within 24 h, as these children likely have
epilepsy (Camfield & Camfield, 2000). Children presenting
with acute symptomatic seizures alone (defined as seizures
in close temporal association with an acute neurologic
insult) were excluded. Similarly, children who had only

febrile seizures were excluded. Children with neonatal seizures were included only if their seizures recurred >28 days
after birth.
Classification of neuroimaging studies and patient
selection
Lesions detected on neuroimaging were categorized by
location (generalized, multifocal, hemispheric, frontal, temporal, parietal, and occipital) and presumed etiology (malformation of cortical development, mesial temporal lobe
sclerosis, tumors, vascular malformation, infarct, or other).
Neuroimaging reports for all cases were available, and
where possible, original neuroimaging studies were
reviewed by two epileptologists (EW and GC) for confirmation of lesion location and etiology. Only patients with single
focal or hemispheric lesion on neuroimaging [brain computed tomography (CT) or MRI] believed to be responsible
for their epilepsy were selected for study. Mesial temporal
lobe sclerosis was defined on the MRI as hippocampal formation atrophy and an increased mesial temporal T2-signal
intensity. Hippocampal formation atrophy is most obvious
using the T1-weighted gradient-echo image in the obliquecoronal plane. The high signal intensity alteration can be
identified using T2-weighted imaging or the fluid attenuated
inversion recovery (FLAIR) sequence in the oblique-coronal
plane (Cascino, 2008). Malformation of cortical development was defined on the MRI as focal cortical thickening,
blurring of the graywhite matter junction, and hyperintensity (on T2-weighted images) of subcortical white matter
tapering toward the ventricle (Colombo et al., 2003).
Chart review and data analysis
Medical records of selected cases were reviewed to determine outcome with or without epilepsy surgery at last follow-up. Outcomes in each of the etiologic categories were
stratified into three groups: (1) seizure freedom for 1 year
at final follow-up (on or off antiepileptic medications), (2)
ongoing seizures but not medically intractable, and (3) medically intractable epilepsy or undergoing epilepsy surgery.
Medically intractable epilepsy was defined as having
seizures more frequently than every 6 months during the
year prior to final follow-up, and failing two or more antiepileptic drugs for lack of efficacy.
All data entry and statistical analysis was performed
using PASW Statistics 18.0 (SPSS Inc., Chicago, IL,
U.S.A.). Correlations were examined using the Fishers
exact test (two sided table). p-Values <0.05 were considered
statistically significant.
This study was approved by the institutional review board
of Mayo Clinic, Rochester.

Results
Three hundred fifty-nine children were newly diagnosed
with epilepsy between 1980 and 2004 while residing in
Epilepsia, 52(8):15221526, 2011
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1524
R. Dhamija et al.
Olmsted County. The mode of onset and etiologies of
seizures in this population has been previously reported
(Wirrell et al., 2011). All children except three were seen on
at least one occasion by a child neurologist who confirmed
the diagnosis of epilepsy. Of the remaining three, two were
diagnosed with epilepsy by a general neurologist and one by
a pediatrician. Prophylactic antiepileptic drug therapy was
commenced in 339 patients, whereas 20 were never treated.
Forty-nine were started on medication after their first
afebrile seizure, and of these, 34 had subsequent seizures
despite medication. Fifteen had only a single seizure, but
had one or more features predicting higher rate of recurrence (specified in Methods) and were commenced on
antiepileptic drug therapy without recurrence.
MRI became available in our center in 1984. Prior to
that, neuroimaging was performed with CT scanning,
which arguably could have missed important epileptogenic
lesions such as mesial temporal sclerosis or certain malformations of cortical development. Over the period of our
study, use of MRI in our entire cohort of new-onset pediatric epilepsy increased, being done in 17 (38%) of 45
patients diagnosed from 19801984, 33 of (53%) 62 diagnosed from 19851989, 47 (67%) of 70 diagnosed from
19901994, 73 (82%) of 89 diagnosed from 19951999,
and 77 (83%) of 93 diagnosed from 20002004 (p < 0.01).
Overall, in our cohort of 359 cases of new-onset pediatric
epilepsy, neuroimaging was performed in 329 (92%) cases,
247 of whom had MRI, and 82 of whom had CT only. Of
those who had MRI, 40 had generalized or multifocal
abnormalities and 36 had either focal or hemispheric
abnormalities. Of those who had CT scans only, 14 had
generalized or multifocal abnormalities and only 1 had a
focal or hemispheric abnormality. In summary, 37 (10%)
were found to have a focal or hemispheric lesion on
neuroimaging responsible for their epilepsy.
Our cohort included 25 male and 12 female patients.
Median age of diagnosis was 89 months (25th percentile
26 months, 75th percentile 142 months) and at follow-up
was 137 months (25th percentile 95 months, 75th percentile
211 months). The clinical details of the patients at presentation and last follow-up are listed in Table 1.
Original imaging studies were reviewed in all but four
cases, as they were no longer available. Etiologies on imaging included encephalomalacia (n = 12), malformations of
cortical development (n = 6), mesial temporal sclerosis
(n = 9), vascular malformations (n = 6) [cavernous hemangioma (n = 2), arteriovenous malformation (n = 2), thrombosed arterial aneurysm (n = 1), Sturge-Weber syndrome
(n = 1)], tumor (n = 2) [ganglioglioma (n = 1), fibrillary
astrocytoma (n = 1)], and other (n = 2) [hypothalamic hamartoma (n = 1), calcified granuloma (n = 1)]. Table 2
summarizes the epilepsy course of patients with each presumed etiology.
Of the six patients with malformations of cortical
development, 5 (83%) were either medically intractable or
Epilepsia, 52(8):15221526, 2011
doi: 10.1111/j.1528-1167.2011.03192.x

Table 1. Detailed clinical characteristics of the 37

patients at onset and last follow-up
Examination at presentation
20 Normal
17 Abnormal
13 Hemiparesis
2 Quadriparesis
2 Clumsiness, hypotonia, extrapyramidal
Seizure type at presentation
11 Secondary generalized tonicclonic seizures
31 Partial seizures
9 Status epilepticus at presentation
Seizure frequency at last follow-up
24 Seizure-free
4 Seizures every 612 months
2 Seizures every 36 months
7 Seizures more than every 3 months
Number of antiepileptics at last follow-up
12 Off all medications
16 On one antiepileptic
8 On two antiepileptics
1 On three antiepileptics
Seizure type during last year of follow-up in patients that were not seizure-free
(n = 13)
6 Secondary generalized tonicclonic seizures
11 Partial seizures

underwent surgery. Of the four treated surgically, at final

follow-up, two were seizure-free and two had ongoing
seizures. Of the two treated with medical therapy alone,
one was seizure-free and the other had medically intractable epilepsy.
Six (67%) of nine patients with mesial temporal sclerosis
were either medically intractable or underwent surgery.
At final follow-up, of the five treated surgically, four were
seizure-free. Of the four treated with medical therapy alone,
three were seizure-free, and the other had medically intractable epilepsy.
Only 3 of the 12 patients with encephalomalacia underwent surgery and of these two were seizure-free at final
follow-up. Of those medically managed, 7 of 9 ultimately
achieved seizure freedom, one had ongoing, but not intractable seizures, and one had medically intractable epilepsy.
Both patients with tumor had surgery for tumor removal.
At last follow-up, one achieved seizure freedom off antiepileptic medications, whereas the other remained intractable.
Of the six patients with a vascular malformation, three
had surgery. Of those treated medically, one was seizure
free and neither of the remaining two had developed medically intractable epilepsy.
Following surgery, seizure freedom at final follow-up
was achieved in 80% with mesial temporal sclerosis, 67%
with encephalomalacia, 67% with vascular malformation,
and 50% with malformations of cortical development.
Twenty-one of 37 subjects (57%) were either medically
intractable at final follow-up or had undergone epilepsy

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Outcome of Epilepsy in Childhood with Focal Lesion on Neuroimaging
Table 2. Detailed description of epilepsy course in different etiologies
Etiology
Epilepsy course
Median follow-up (months)
25th percentile, 75th percentile
Median age at diagnosis (months)
25th percentile, 75th percentile
Surgical treatment
Seizure-free
Intractable
Median follow-up (months)
Medical treatment alone
Seizure-free
Intractable
Median follow-up (months)

MCD
n=6

MTS
n=9

131
(86, 177)
35
(<1, 150)
4/6 (67)
2/4 (50)
2/4 (50)
131
2/6 (29)
1/2 (50)
1/2 (50)
165

234
(133, 260)
115
(67, 173)
5/9 (56)
4/5 (0)
0
260
4/9 (44)
3/4 (75)
1/4 (25)
135

Encephalomalacia
n = 12
150
(85, 189)
85
(31, 121)
3/12 (25)
2/3 (67)
1/3 (33%)
191
9/12 (75)
7/9 (77)
1/9
149

Tumor
n=2
108
51
2/2 (100)
1/2 (50)
1/2 (50)

Vascular malformation
n=6
129
(69, 176)
134
(5, 191)
3/6 (50)
2/3 (67)
1/3 (33%)
122
3/6 (50)
1/3 (33)
0
135

MCD, malformation of cortical development; MTS, mesial temporal sclerosis.

surgery. Compared to the other etiologies, encephalomalacia was significantly less likely to correlate with this outcome (p < 0.012).

Discussion
In our population-based cohort of new-onset pediatric
epilepsy, 10% had a focal neuroimaging abnormality that
was felt to be responsible for their epilepsy. Encephalomalacia was the most common abnormality (32%), followed by
mesial temporal sclerosis (24%), malformation of cortical
development (16%), vascular malformations (16%), and
tumor (5%). In previous surgical series of children with epilepsy, malformations of cortical development have been
found to be the most common cause of medically intractable
focal onset epilepsy (Lerner et al., 2009). The difference
likely relates to our methodology. We identified a population-based cohort of newly diagnosed children with epilepsy, then selected for study both medically and surgically
treated patients with lesional neuroimaging. Of this cohort,
we found that the presence of encephalomalacia has the
most favorable outcome and predicts the least likelihood of
being intractable or undergoing surgery.
Previous studies have reported that mesial temporal sclerosis is associated with a high likelihood of intractable epilepsy (Semah & Ryvlin, 2005). Surprisingly, in our cohort,
one third of patients with this etiology were seizure-free at
final follow-up with medical treatment alone after prolonged follow-up. Similar to prior reports, we found that
surgical outcome is favorable with this etiology, with 80%
achieving seizure-freedom (Shaefi & Harkness, 2003;
Wieser et al., 2003; Mihara et al., 2004; Nakase et al.,
2007; Smyth et al., 2007; Spencer & Huh, 2008).
Surgical outcomes are typically less favorable for malformations of cortical development, with reported rates of seizure freedom of 49%, 44%, and 33%, respectively, at 1, 2,

and 5 years in one retrospective study (Phi et al., 2010).

These rates are comparable to the 50% rate of seizure freedom in our cohort of children with malformations of cortical
development who underwent surgery.
Not surprisingly, the majority of children (57%) in our
cohort with a focal imaging lesion either underwent surgery
(n = 18) or had medically intractable epilepsy at final follow-up (n = 3). This proportion is significantly higher than
seen in our overall cohort of children with new-onset
epilepsy, where only 20% had either undergone epilepsy
surgery or had medically intractable epilepsy at final follow-up (Wirrell et al., 2011). What is notable, however, was
that poor outcome was not experienced by all children with
focal lesions. Nearly one-third achieved seizure freedom
with medical management alone, including 33% with
mesial temporal sclerosis and 58% with encephalomalacia.
Although these finding were not statistically significant
among the different etiologies, the trends are striking and
deserve further investigation utilizing larger populationbased studies.
Over the course of our study period from 19802004,
significant improvements in neuroimaging were made, with
the advent of MRI, which became available in our center in
1984. Prior to that, neuroimaging was performed with CT
scanning, which arguably could have missed important
epileptogenic lesions such as mesial temporal sclerosis or
certain malformations of cortical development. However,
as most of our cohort was followed longitudinally, those
whose seizures were poorly controlled ultimately underwent MRI.
Our study is unique given that it is a population-based
study of children with epilepsy with focal or hemispheric
lesions on neuroimaging with long-term follow-up. Unlike
previous studies on this population that have been either
surgical series or hospital-based studies, our study cohort
is free from selection bias. The major weakness of our study
Epilepsia, 52(8):15221526, 2011
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1526
R. Dhamija et al.
is small sample size. Such size limits our ability to detect
statistically significant difference in the outcome of children
among the different etiologies.
We conclude that although finding a focal lesion on neuroimaging in a child with newly diagnosed epilepsy portends a higher risk of medical intractability, outcome is not
always bleak. Medical management alone was associated
with seizure freedom in nearly one third of cases, particularly if the etiology is encephalomalacia. Larger populationbased studies are needed to confirm whether lesion etiology
predicts outcome.

Disclosure
Dr. E. Wirrell serves on the Editorial Boards for Epilepsia, Canadian
Journal of Neurological Sciences, and Journal of Child Neurology. Dr. G.
CascinoResearch Grant: Neuro Pace, Inc. (coinvestigator); Honoraria:
American Academy of Neurology; Research Grant: National Institutes of
Health R01NS053998 (principal investigator); Associate Editor: Neurology
(published by the American Academy of Neurology). The remaining
authors have no relevant relationships to disclose.
We confirm that we have read the Journals position on issues involved in
ethical publication and affirm that this report is consistent with those guidelines.

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