OUTCOME OF FRONTAL LOBE

EPILEPSY SURGERY
3rd Journal Reading
Wednesday, 19 November 2014

Presenter : dr. Steviyani

Moderator : dr. Iskandar Nasution Sp.S FINS

INTRODUCTION
Epilepsy surgery is a well-established therapy for
frontal lobe epilepsy (FLE)
Success rates vary between 20 and 80%, with most
studies reporting a favorable seizure outcome of
Engel class I or class IA in around 50%of patients
However, outcome measures of those studies are
not uniform and often focus on short-term outcome
It is well established that FLE surgery is less
successful than temporal lobe epilepsy surgery with
respect to seizure outcome

 Resections of the supplementary motor area (SMA) are

thought to have a relatively more favorable outcome
than resections in other regions within the frontal lobes
Various surgical centers have different surgical
approaches and indication criteria for FLE surgery
A potential limitation of many studies investigating
outcome following resection for FLE is the reliance on
one specific outcome measure, which is commonly
freedom from disabling seizures or Engel outcome
classification

 The present study evaluated multiple outcome

measures following surgery for FLE including
several seizure outcome measures, employment,
and reductions in AED
Furthermore, neuropsychological performance and
depression were also examined, as they have
been reported to affect well-being more
significantly than seizure outcome

METHODS
Patients with a diagnosis of intractable FLE and
subsequent intracranial EEG study and/or FLE surgery
were enrolled into the study
For patients who did not have invasive EEG monitoring,
the decision to perform resective surgery was based on
scalp EEG monitoring and a corresponding lesion in
noneloquent cortex. Postoperative follow-up had to be
well-documented for a minimum of 12 months
Presurgical evaluation at the Dartmouth-Hitchcock
comprehensive Epilepsy Center included comprehensive
seizure history, scalp video-EEG monitoring, high
resolution MRI, neuropsychological testing, ictal SPECT,
PET, and intracranial EEG

 Follow-up data were obtained via repeated clinic visits

Postoperative neuropsychological testing was
performed a minimum of 5 months after surgery
Ictal SPECT, interictal scalp EEG, ictal scalp EEG,
and PET results were classified as either concordant
or not concordant with the area resected

Seizure outcome
Seizure-related outcome measures were tabulated based
on yearly follow-up data
This included Engel class and subclasses, the International
League Against Epilepsy classification system, time to the
patients first postoperative seizure, and whether the patient
was free of disabling seizures during the last year of followup
The time to the first postoperative seizure was charted for
use in Kaplan-Meier analysis
All outcome data were collected by personnel (SL) not
involved in clinical care of the patients

Employment outcome
Postoperative employment was compared to preoperative
employment.
Part-time work, full-time work, full-time student

AED Outcome
Postsurgical reduction in number of antiepileptic drugs
(AEDs) or reduction in AED dosage was also considered as
an outcome measure
The number and dosage of AEDs at the last follow-up was
compared to the number and dosage of AEDs taken
immediately before surgery

Neuropsychological testing

All tests, however, occurred

within 2 years before or after
surgery
Intellectual functioning
WAIS
Memory CVLT Total Trials
15 and Long-Delay Free
Recall, & the Logical Memory
subtest from the WMS
Language Boston
Naming Test
phonemic fluency the
Controlled Oral Word
Association Test or

the Verbal Fluency subtest

Delis-Kaplan Executive Function
System.
Processing speed Trail
Making Test Part A or
Condition 2 DKEFS Trail
Making
Executive functions Trail
Making Test B or condition 4
DKEFS Trail Making
Depression Beck Depression
Inventory

STATISTICAL ANALYSIS
Univariate and multivariate statistical analyses were utilized to
test for predictors of outcome
Fishers exact test when small group size precluded the use of
chi-square analysis, and paired t-tests
Kruskal-Wallis tests were also utilized for analysis of
depression scores
Multiple logistic regression was then utilized to test for
significant predictors of seizure, employment, and
neuropsychological outcome
Kaplan-Meier analysis was used to calculate the probability of
remaining Engel class I throughout the follow-up

RESULTS

PROGNOSTIC
FACTORS
The presence of a lesion on MRI did not correlate with Engel
outcome, suggesting that patients who were MRI negative
were not less likely to be seizure-free or to have a class I
outcome than MRI-positive patients (p = 0.287;p = 0.672)
There was not a statistically significant difference between
patients with normal pathology versus abnormal pathology in
terms of achieving either seizure freedom (Engel IA; p =
0.513; Table S1) or a class I Engel outcome (p = 0.199; Table
S1)
Variables related to intracranial monitoring such as the type of
implant and number of electrodes did not correlate with
seizure outcome

 Interictal EEG findings were not significantly

associated with Engel class outcome
If the ictal scalp EEG results were concordant with
the lateralization of the seizure focus, the patients
were more likely than others to have a class IA
outcome (p = 0.026; n = 53)
The only risk factor to correlate with outcome was
head trauma (p = 0.044), and patients with this risk
factor were less likely to have a class IA outcome

SEIZURE PATTERNS
The most common postoperative seizure pattern
was free of disabling seizures (found in 33% of
patients)
EMPLOYMENT
OUTCOME
Postoperative employment was associated with a
class Ioutcome (p = 0.01). Therefore, patients who
did not have class I outcomes were more likely to
not be employed following surgery.

NEUROPSYCHOLOGICAL
OUTCOME
There was no significant relationship between preoperative
or postoperative depression score and seizure-onset zone, if
examined independently.

AED CHANGES
Sixteen patients (28%) took a reduced number of AEDs
at last follow-up, whereas 9 (16%) took an increased
number of AEDs. Fifteen patients (26%) remained on
identical medications as preoperatively, with eight (14%)
on reduced doses of those same AEDs

VAGUS NERVE
STIMULATION
Eight (14%) patients underwent vagus nerve stimulation
(VNS) after resective surgery. VNS was placed on average
48 months after the resective surgery

COMPLICATIONS
Three resective patients (5.2%) experienced
complications and were readmitted. Two had
cerebrospinal fluid (CSF) leaks and one had an infection

DISCUSSION

Our observation of an overall Engel class I outcome

of 57% and a combined Engel class I and II outcome
of 73% is consistent with previous reported studies

In our series, patients with negative MRI did have

outcomes equally good as patients with definite
lesions, which contradicts most previous reports
This may be an effect of sample size

 Seizure pattern : These investigators reported a

running-down effect (several postoperative
seizures before seizure freedom) in 11%, which is
similar to 7% in this study and others
Standardized quality of life measures were not
universally available, but epilepsy surgery resulted
in some employment gains and reflects previous
findings that employment gains correlate with
better seizure outcome

Neuropsychological outcome : In the present

investigation, preoperative neuropsychological scores
did not predict seizure outcome, and surgery was not
associated with significant change in
neuropsychological functioning. Other investigations
have yielded inconsistent changes, with some
reporting memory improvement in seizure-free patients
differences in the specific frontal regions that were
resected

LIMITATION

It is a retrospective review. Small sample sizes

in subgroup analysis may mask subtle effects.
the retrospective analysis of neuropsychological
outcome was inherently limited because not all
patients took the same batteries and updated
versions of certain tests were released during
the retrospective period

CONCLUSION
FLE surgery in all locations within the frontal
lobe improves seizure outcome, but
psychosocial outcome and comorbidities such
as depression need more investigation
Epilepsy surgery should be offered to FLE
patients, even if MRI is negative
Overall outcome can also be favorable even if
the patient is not completely seizure-free