Department of Neurosurgery, AP-HP, La Pitié-Salpêtrière-Charles Foix University Hospital, Paris, France.
Sorbonne University, UPMC University of Paris 06, Paris, France.
Epilepsia. 2017 Aug;58(8):1473-1485. doi: 10.1111/epi.13831. Epub 2017 Jun 28.
The reasons for failure of surgical treatment for mesial temporal lobe epilepsy (MTLE) associated with hippocampal sclerosis (HS) remain unclear. This retrospective study analyzed seizure, cognitive, and psychiatric outcomes, searching for factors associated with seizure relapse or cognitive and psychiatric deterioration after MTLE-HS surgery.
Seizure, cognitive, and psychiatric outcomes were reviewed after 389 surgeries performed between 1990 and 2015 on patients aged 15-67 years at a tertiary center. Three surgical approaches were used: anterior temporal lobectomy (ATL; n = 209), transcortical selective amygdalohippocampectomy (SAH; n = 144), and transsylvian SAH (n = 36).
With an average follow-up of 8.7 years (range = 1.0-25.2), seizure outcome was classified as Engel I in 83.7% and Engel Ia in 57.1% of patients. The histological classification of HS was type 1 for 75.3% of patients, type 2 for 18.7%, and type 3 for 1.2%. Two factors were significantly associated with seizure recurrence: past history of status epilepticus and preoperative intracranial electroencephalographic recording. In contrast, neither HS type, the presence of a dual pathology, nor surgical approach was associated with seizure outcome. Risk of cognitive impairment was 3.12 (95% confidence interval = 1.27-7.70), greater in patients after ATL than in patients after transcortical SAH. A presurgical psychiatric history and postoperative cognitive impairment were associated with poor psychiatric outcome.
The SAH and ATL approaches have similar beneficial effects on seizure control, whereas transcortical SAH tends to minimize cognitive deterioration after surgery. Variation in postsurgical outcome with the class of HS should be investigated further.
手术治疗与海马硬化（HS）相关的内侧颞叶癫痫（MTLE）失败的原因尚不清楚。本回顾性研究分析了癫痫、认知和精神状态结局，寻找与 MTLE-HS 手术后癫痫复发或认知和精神状态恶化相关的因素。
在一家三级中心，对 1990 年至 2015 年间接受手术的年龄在 15-67 岁的患者的 389 例手术进行了癫痫、认知和精神状态结局的回顾。使用了三种手术方法：前颞叶切除术（ATL；n=209）、皮质切开选择性杏仁核-海马切除术（SAH；n=144）和经侧裂 SAH（n=36）。
平均随访 8.7 年（范围=1.0-25.2），83.7%的患者癫痫发作结局为 Engel I 级，57.1%的患者为 Engel Ia 级。HS 的组织学分类为 75.3%的患者为 1 型，18.7%的患者为 2 型，1.2%的患者为 3 型。有两个因素与癫痫复发显著相关：既往癫痫持续状态病史和术前颅内脑电图记录。相比之下，HS 类型、存在双重病变或手术方法均与癫痫发作结局无关。认知障碍的风险为 3.12（95%置信区间=1.27-7.70），ATL 术后患者的风险高于经皮质 SAH 术后患者。术前精神病史和术后认知障碍与较差的精神状态结局相关。
SAH 和 ATL 方法对控制癫痫发作具有相似的有益效果，而经皮质 SAH 术后更倾向于最小化认知恶化。应该进一步研究 HS 分级与术后结局变化的关系。
