EDITORIAL
Memory after temporal lobe epilepsy surgery
Brian D. Bell, PhD
Anna R. Giovagnoli, MD
Address correspondence and
reprint requests to Dr. Brian D.
Bell, University of Wisconsin
School of Medicine and Public
Health, Department of
Neurology, 600 Highland Ave.,
Madison WI, 53792
bell@neurology.wisc.edu
Neurology® 2008;71:1302–1303
See page 1319
1302
Risk and reward
Anterior temporal lobectomy (ATL) is a common
surgical intervention for drug-resistant mesial tempo-
ral lobe epilepsy (mTLE) that results in seizure free-
dom for approximately two-thirds of patients and
reduces seizure frequency in about 15% more.1 Felic-
itous seizure outcome often is accompanied by stabil-
ity of cognitive performance because the resected
anterior temporal lobe, especially the hippocampus,
was structurally and functionally abnormal before
ATL, as demonstrated by MRI, PET, EEG, and neu-
ropsychological assessment. In some cases, however,
the postsurgical summary is not all fit for banner and
blazon. Devastating memory loss after ATL has been
quite rare since it was discovered more than 50 years
ago that bilateral hippocampal ablation or injury
could result in permanent global amnesia. However,
a sizable minority of patients with ATL experience a
post-ATL decrease in performance on one or more
standardized memory tests. During the past 20 years,
the potential epilepsy, cognitive, and demographic vari-
ables associated with this post-ATL memory decline have
come under close scrutiny. In particular, since the 1990s
preoperative counseling of the individual mTLE patient
has been facilitated as these risk factors have been identified
and quantified through regression analyses.2,3 Across stud-
ies, side of surgery, preoperative memory performance, age
at seizure onset, illness duration, and severity of tissue pa-
thology have been among the key variables influencing
memory outcome.
Understandably, efforts to predict post-ATL
change at the individual level have focused on mem-
ory decline. The occurrence of postoperative im-
provement in memory functions lateralized to the
unoperated temporal lobe in some patients with ATL
has been described before.4,5 However, statistical pre-
diction of improvement prior to surgery generally
has not been an emphasis of study. In this issue of
Neurology®, in an article titled “Improvements in
memory function following anterior temporal lobe
resection for epilepsy,” Baxendale et al.6 report not
e-Pub ahead of print on September 10, 2008, at www.neurology.org.
From the Department of Neurology (B.D.B.), University of Wisconsin School of Medicine and Public Health, Madison; W.S. Middleton Memorial
Veterans Hospital (B.D.B.), Madison, WI; and Carlo Besta National Neurological Institute (A.R.G.), Department of Clinical Neurosciences,
Neuropsychology Laboratory, Milan, Italy.
Disclosure: The authors report no disclosures.
Copyright © 2008 by AAN Enterprises, Inc.
just that 1) a minority of left and right ATL cases do
indeed perform better on some memory tests after
surgery and 2) the improvements occurred most of-
ten on tests measuring memory functions usually as-
sociated with the unoperated temporal lobe, but also
that 3) the likelihood of improvement can be pre-
dicted by specific variables available presurgically.
When memory test improvement occurred in the
Baxendale et al. investigation, it typically involved
auditory (list learning) memory gain in individual
right ATL patients (23%) and visual (design learn-
ing) memory improvement in left ATL patients
(16%). The main predictors of post-ATL memory
improvement were side of surgery, preoperative levels
of performance in memory and IQ, and duration of
epilepsy. It is notable that the mean age at onset of
epilepsy in this study was relatively low for both the
left and right mTLE groups (median ⫽ 8). Although
age at onset was not a significant predictor of mem-
ory improvement in the study by Baxendale et al.,
the neuropsychological literature demonstrates that
early onset of mTLE is a favorable characteristic for
those undergoing ATL. As discussed by the authors,
both early functional reorganization and anatomic-
functional reserve may in part explain the memory
improvement in this study.
Strengths of the Baxendale et al. study are the size
and homogeneity of the sample, as all 237 partici-
pants had unilateral hippocampal sclerosis and no
other structural lesions. Another strength is that the
authors used reliable change index (RCI) criteria to
measure test change, although they did not describe
details about the derivation of the RCIs. From a clin-
ical standpoint, the authors point out the encourag-
ing result that there were a number of individuals for
whom a memory test score improved from impaired
or well below average to average or better.
Not unexpectedly, none of the right ATL patients
and only 2% of the left ATL group demonstrated
improvement on both the verbal and visual memory
measures administered. This finding suggests that,
even for the select patients deemed to have a chance
for improvement in memory functioning, any opti-
mism expressed during presurgical counseling about
the potential effects of ATL on memory should be
relatively muted. Questions remain open as to pre-
cisely which memory mechanisms gain from surgery
and which factors may predict a positive outcome in
patients with TLE who have other pathology or un-
dergo a different surgical approach. Nevertheless, the
data provided by Baxendale et al. offer an extra ray of
hope for some individuals considering epilepsy sur-
gery. In addition to advising a subset of patients they
are at risk for memory decline should ATL be per-
formed, treaters now have the means to inform a for-
tunate minority that after temporal lobe epilepsy
surgery they may experience some gain in memory
functioning as well as good seizure outcome.
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Neurology 71 October 21, 2008 1303