Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.
Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.
Epilepsia Open. 2023 Mar;8(1):12-31. doi: 10.1002/epi4.12663. Epub 2022 Nov 3.
Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.
岛叶癫痫（IE）是一种越来越被认识到的药物难治性癫痫的病因，适合手术治疗。然而，对手术控制不佳和永久性神经功能障碍的担忧阻碍了 IE 手术的广泛应用。我们进行了一项系统回顾和个体参与者数据荟萃分析，以确定手术治疗 IE 的疗效和安全性，并确定结局的预测因素。在 2483 个独特的引文，24 项回顾性研究报告了 312 名参与者符合纳入标准。中位随访时间为 2.58 年（范围，0-17 年），206 名（66.7%）患者在最后一次随访时无癫痫发作。手术时年龄较小（≤18 岁；HR=1.70，95%CI=1.09-2.66，P=0.022）和使用侵入性脑电图监测（HR=1.97，95%CI=1.04-3.74，P=0.039）与癫痫复发时间较短显著相关。与开放性切除相比，进行磁共振引导激光消融或射频消融（OR=2.05，95%CI=1.08-3.89，P=0.028）与最后随访时的手术结果不佳（Engel II-IV）独立相关。42.5%的患者术后出现神经系统并发症，最常见的是运动障碍（29.9%）。永久性神经系统并发症发生在 7.8%的手术中，包括 5%和 1.4%的永久性运动障碍和构音障碍发生率。额叶岛盖切除术与运动障碍的可能性更大有关（OR=2.75，95%CI=1.46-5.15，P=0.002）。优势半球切除术与构音障碍独立相关（OR=13.09，95%CI=2.22-77.14，P=0.005），尽管观察到的语言缺陷都不是永久性的。IE 的手术治疗具有良好的疗效/安全性。大多数患者无癫痫发作，神经功能缺损主要是短暂的。儿童患者和需要侵入性监测或接受立体定向消融手术的患者无癫痫发作的比例较低。如果认为其不在致痫区，则应避免侵犯额叶岛盖。经选择的接受优势半球切除术的患者更有可能出现短暂的语言障碍；然而，永久性缺陷的风险非常低。
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