McIntosh Anne M, Kalnins Renate M, Mitchell L Anne, Fabinyi Gavin C A, Briellmann Regula S, Berkovic Samuel F
Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.
Brain. 2004 Sep;127(Pt 9):2018-30. doi: 10.1093/brain/awh221. Epub 2004 Jun 23.
There is little information available relevant to long-term seizure outcome after anterior temporal lobectomy, particularly at extended postoperative periods. The aim of this study was an in-depth examination of patterns of longitudinal outcome and potential risk factors for seizure recurrence after lobectomy, utilizing a large patient sample with long follow-up. Included were 325 patients who underwent anterior temporal lobectomy between 1978 and 1998 (mean follow-up 9.6 +/- 4.2 years). Retrospective data were analysed using survival analysis and multivariate regression with Cox proportional hazard models. The probability of complete seizure freedom at 2 years post-surgery was 55.3% [95% confidence interval (CI) 50-61]; at 5 years, 47.7% (95% CI 42-53); and at 10 postoperative years it was 41% (95% CI 36-48). Patients with discrete abnormalities preoperatively (i.e. lesions and hippocampal sclerosis) had a significantly higher probability of seizure freedom than patients without obvious abnormality. The latter group had a pattern of recurrence similar to that in patients with lesions outside the area of excision. After adjustment for preoperative pathology, only the presence of preoperative secondarily generalized seizures had a significant association with recurrence [occasional preoperative generalized seizures, hazard ratio (HR) 1.6, 95% CI 1.1-2.3; frequent seizures, HR 2.0, 95% CI 1.4-2.9 compared with absence of preoperative generalized seizures]. Duration of preoperative epilepsy, age of seizure onset and age at surgery did not have an effect on outcome. Patients with two seizure-free postoperative years had a 74% (95% CI 66-81) probability of seizure freedom by 10 postoperative years. This late seizure recurrence was not associated with any identified risk factors. Specifically, patients with hippocampal sclerosis were not at higher risk. Surprisingly, complete discontinuation of anti-epileptic drugs (AEDs) after two postoperative years was not associated with an increased risk of recurrence (HR 1.03, 95% CI 0.5-2.1). This may be because selection of patients for AED discontinuation is biased towards those individuals perceived as 'low risk'. The results of this study indicate that the lack of an obvious abnormality or the presence of diffuse pathology, and preoperative secondarily generalized seizures are risk factors for recurrence after surgery. Late recurrence after initial seizure freedom is not a rare event; risk factors specific to this phenomenon are as yet unidentified.
目前关于前颞叶切除术后长期癫痫发作结局的信息较少，尤其是在术后较长时间段。本研究的目的是利用一个随访时间长的大型患者样本，深入研究叶切除术后的纵向结局模式和癫痫复发的潜在危险因素。研究纳入了1978年至1998年间接受前颞叶切除术的325例患者（平均随访时间9.6±4.2年）。使用生存分析和Cox比例风险模型进行多变量回归分析回顾性数据。术后2年完全无癫痫发作的概率为55.3%[95%置信区间（CI）50 - 61]；术后5年为47.7%（95%CI 42 - 53）；术后10年为41%（95%CI 36 - 48）。术前有离散性异常（即病变和海马硬化）的患者无癫痫发作的概率显著高于无明显异常的患者。后一组的复发模式与切除区域外有病变的患者相似。在对术前病理进行调整后，只有术前有继发性全身性癫痫发作与复发有显著关联[偶尔有术前全身性癫痫发作，风险比（HR）1.6，95%CI 1.1 - 2.3；频繁发作，HR 2.0，95%CI 1.4 - 2.9，与无术前全身性癫痫发作相比]。术前癫痫发作持续时间、癫痫发作起始年龄和手术年龄对结局无影响。术后有两年无癫痫发作的患者术后10年无癫痫发作的概率为74%（95%CI 66 - 81）。这种晚期癫痫复发与任何已确定的危险因素均无关联。具体而言，有海马硬化的患者风险并不更高。令人惊讶的是，术后两年后完全停用抗癫痫药物（AEDs）与复发风险增加无关（HR 1.03，95%CI 0.5 - 2.1）。这可能是因为选择停用AEDs的患者偏向于那些被认为“低风险”的个体。本研究结果表明，缺乏明显异常或存在弥漫性病变以及术前继发性全身性癫痫发作是术后复发的危险因素。初始无癫痫发作后的晚期复发并非罕见事件；尚未发现针对这一现象的特定危险因素。
