Raghu Ashley L B, Lau Jonathan, Stern Matthew A, Faraj Razan R, Isbaine Faical, Grogan Dayton, Bullinger Katie, Roth Rebecca W, Dickey Adam S, Willie Jon T, Drane Daniel L, Gross Robert E
Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
Epilepsia. 2025 Feb;66(2):458-470. doi: 10.1111/epi.18188. Epub 2024 Dec 20.
Stereotactic laser amygdalohippocampotomy (SLAH) is a minimally invasive procedure for mesial temporal lobe epilepsy that preserves more tissue than open procedures. As a result, although patients have better functional outcomes, more patients do not achieve seizure freedom. The rate at which this occurs is evolving with improved surgical practices. However, the risks and benefits of further surgical management for these patients remains a question with limited data to guide decision-making.
We retrospectively reviewed a continuous series (2011-2019) of SLAH operations at our institution to determine trends in surgical management, identifying cases where further surgery was performed. Pre-operative and follow-up seizure, cognitive, and functional data, and surgical complications were collated.
Of 108 patients undergoing primary SLAH, 21 (19%) underwent further surgery (23 procedures). Stereo-electroencephalography (SEEG) informed seven procedures (30%). There was a trend for quicker SLAH failure in the earlier patients. Similarly, surgical chronology was associated with progression to repeat surgery (p = .007). At 1-year follow-up, 6 of 13 patients (46%) achieved seizure freedom after repeat SLAH and 5 of 8 patients (63%) achieved seizure freedom after anterior temporal lobectomy (ATL), one of whom had failed two SLAHs. Two of three patients undergoing an ablation outside the mesial temporal lobe achieved seizure freedom at 1 year. Neuropsychological sequelae were more prevalent with ATL than SLAH, including decline in visual naming (p = .01) and functional status (p = .007).
Repeat SLAH and ATL post-SLAH are both practicable and can be effective. Surgical experience, risk to cognition, and marginal benefit relative to existing improvement are principal considerations for further surgery.
立体定向激光杏仁核海马切开术（SLAH）是一种用于治疗内侧颞叶癫痫的微创手术，与开放性手术相比，它能保留更多组织。因此，尽管患者的功能预后较好，但仍有更多患者无法实现无癫痫发作。随着手术技术的改进，这种情况发生的比率也在不断变化。然而，对于这些患者进一步手术治疗的风险和益处仍是一个问题，可供指导决策的数据有限。
我们回顾性分析了我院2011年至2019年连续进行的一系列SLAH手术，以确定手术管理的趋势，找出进行了进一步手术的病例。整理了术前和术后的癫痫发作、认知和功能数据以及手术并发症。
在108例行初次SLAH的患者中，21例（19%）接受了进一步手术（共23次手术）。立体定向脑电图（SEEG）指导了7次手术（30%）。早期患者中SLAH失败的趋势更快。同样，手术时间与再次手术的进展相关（p = 0.007）。在1年的随访中，13例患者中有6例（46%）在再次SLAH后实现无癫痫发作，8例患者中有5例（63%）在颞叶前切除术（ATL）后实现无癫痫发作，其中1例患者两次SLAH均失败。3例在内侧颞叶以外进行消融手术的患者中有2例在1年后实现无癫痫发作。与SLAH相比，ATL的神经心理学后遗症更为普遍，包括视觉命名能力下降（p = 0.01）和功能状态下降（p = 0.007）。
再次SLAH和SLAH术后的ATL都是可行的，并且可能有效。手术经验、对认知的风险以及相对于现有改善的边际效益是进一步手术的主要考虑因素。
