Service de Neurochirurgie Fonctionnelle

Sainte-Foy-lès-Lyon, France

Service de Neurochirurgie Fonctionnelle

Sainte-Foy-lès-Lyon, France
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Catenoix H.,Service de Neurologie Fonctionnelle et dEpileptologie | Catenoix H.,University of Lyon | Montavont A.,Service de Neurologie Fonctionnelle et dEpileptologie | Montavont A.,University of Lyon | And 9 more authors.
Seizure | Year: 2013

Purpose: Mesio-temporal ictal semiology is sometimes observed in patients with large multilobar lesion. In this situation, surgery is often discarded because of the lesion size and/or suspicion of extended or multifocal epileptogenic areas. In this retrospective study we evaluated the surgical outcome of such patients in order to assess whether the electro-clinical presentation of seizures could be a prognostic marker of surgical outcome. Methods: Among the temporal lobe epilepsy population explored in our department between 2000 and 2011 (240 patients), we identified 7 patients who presented an extensive lesion on brain Magnetic Resonance Imaging (MRI) (multilobar in four, hemispheric in two, and bilateral in one). All patients underwent 18Fluorodeoxyglucose Positron Emission Tomography, which showed large, hemispheric or multilobar, areas of glucose hypometabolism. Because of the large lesion size, all patients were explored by stereoelectroencephalography (SEEG) before taking a decision regarding surgical indication. Results: SEEG confirmed the temporal origin of the seizures and discarded the possibility of multiple epileptogenic zones. A temporal lobectomy, tailored on the basis of SEEG data, was proposed to the seven patients. The seven patients are classified Engel class I after the surgery (mean follow-up: 37.4 ± 22.1 months). Conclusion: Our data thus suggest that, even in the absence of hippocampal MRI abnormality, ictal symptoms compatible with a temporal origin of seizures should be considered as a reliable indicator for surgery eligibility regardless of MRI lesion size. On the basis of our findings, the mesio-temporal semiology of seizures appears as one of the most reliable markers of operability in patients with large MRI lesions. These patients should not be excluded a priori from invasive exploration and surgical treatment, even if a large portion of their lesion is likely to be left in place after surgery. © 2013 British Epilepsy Association.


Guenot M.,Service de Neurochirurgie Fonctionnelle
Advances and technical standards in neurosurgery | Year: 2011

Previous literature includes numerous reports of acute stereotactic ablation for epilepsy. Most reports focus on amygdalotomies or amygdalohippocampotomies, some others focus on various extra-limbic targets. These stereotactic techniques proved to have a less favourable outcome than that of standard surgery, so that their rather disappointing benefit/risk ratio explains why they have been largely abandoned. However, depth electrode recordings may be required in some cases of epilepsy surgery to delineate the best region of cortical resection. We usually implant depth electrodes according to Talairach's stereo electroencephalography (SEEG) methodology. Using these chronically implanted depth electrodes, we are able to perform radiofrequency (RF)-thermolesions of the epileptic foci. This paper reports the technical data required to perform such multiple cortical thermolesions, as well as the results in terms of seizure outcome in a group of 41 patients. TECHNICAL DATA: Lesions are placed in the cortex areas showing either a low amplitude fast pattern or spike-wave discharges at the onset of the seizures. Interictal paroxysmal activities are not considered for planning thermocoagulation sites. All targets are first functionally evaluated using electrical stimulation. Only those showing no clinical response to stimulation are selected for thermolesion, including sites located inside or near primary functional area. Lesions are performed using 120mA bipolar current (50 V), applied for 10-30 sec. Each thermocoagulation produces a 5-7mm diameter cortical lesion. A total of 2-31 lesions were performed in each of the 41 patients. Lesions are placed without anaesthesia. 20 patients (48.7%) experienced a seizure frequency decrease of at least 50% that was more than 80% in eight of them. One patient was seizure free after RF thermocoagulation. In 21 patients, no significant reduction of the seizure frequency was observed. Amongst the characteristics of the disease (age and sex of the patient, lobar localization of the EZ) and the characteristics of the thermocoagulations (topography, lateralization, number, morphology of the lesions on MRI) no factor was significantly linked to the outcome. However, the best results were clearly observed in epilepsies symptomatic of a cortical development malformation (CDM), with 67% of responders in this group of 20 patients (p = 0.052). Three transient post-procedure side-effects, consisting of paraesthetic sensations in the mouth (2 cases), and mild apraxia of the hand, were observed. SEEG-guided-RF-thermolesioning is a safe technique. Our results indicate that such lesions can lead to a significant reduction of seizure frequency. Our experience suggests that SEEG-guided RF thermocoagulation should be dedicated to drug-resistant epileptic patients for whom conventional resection surgery is risky or contra-indicated on the basis of invasive pre-surgical evaluation, particularly those suffering from epilepsy symptomatic of cortical development malformation.


PubMed | Service de Neurochirurgie Fonctionnelle
Type: | Journal: Advances and technical standards in neurosurgery | Year: 2011

Previous literature includes numerous reports of acute stereotactic ablation for epilepsy. Most reports focus on amygdalotomies or amygdalohippocampotomies, some others focus on various extra-limbic targets. These stereotactic techniques proved to have a less favourable outcome than that of standard surgery, so that their rather disappointing benefit/risk ratio explains why they have been largely abandoned. However, depth electrode recordings may be required in some cases of epilepsy surgery to delineate the best region of cortical resection. We usually implant depth electrodes according to Talairachs stereo electroencephalography (SEEG) methodology. Using these chronically implanted depth electrodes, we are able to perform radiofrequency (RF)-thermolesions of the epileptic foci. This paper reports the technical data required to perform such multiple cortical thermolesions, as well as the results in terms of seizure outcome in a group of 41 patients. TECHNICAL DATA: Lesions are placed in the cortex areas showing either a low amplitude fast pattern or spike-wave discharges at the onset of the seizures. Interictal paroxysmal activities are not considered for planning thermocoagulation sites. All targets are first functionally evaluated using electrical stimulation. Only those showing no clinical response to stimulation are selected for thermolesion, including sites located inside or near primary functional area. Lesions are performed using 120mA bipolar current (50 V), applied for 10-30 sec. Each thermocoagulation produces a 5-7mm diameter cortical lesion. A total of 2-31 lesions were performed in each of the 41 patients. Lesions are placed without anaesthesia.20 patients (48.7%) experienced a seizure frequency decrease of at least 50% that was more than 80% in eight of them. One patient was seizure free after RF thermocoagulation. In 21 patients, no significant reduction of the seizure frequency was observed. Amongst the characteristics of the disease (age and sex of the patient, lobar localization of the EZ) and the characteristics of the thermocoagulations (topography, lateralization, number, morphology of the lesions on MRI) no factor was significantly linked to the outcome. However, the best results were clearly observed in epilepsies symptomatic of a cortical development malformation (CDM), with 67% of responders in this group of 20 patients (p = 0.052). Three transient post-procedure side-effects, consisting of paraesthetic sensations in the mouth (2 cases), and mild apraxia of the hand, were observed.SEEG-guided-RF-thermolesioning is a safe technique. Our results indicate that such lesions can lead to a significant reduction of seizure frequency. Our experience suggests that SEEG-guided RF thermocoagulation should be dedicated to drug-resistant epileptic patients for whom conventional resection surgery is risky or contra-indicated on the basis of invasive pre-surgical evaluation, particularly those suffering from epilepsy symptomatic of cortical development malformation.

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