Drug-resistant temporal lobe epilepsy due to cavernous malformations

Sergio Paolini, Roberta Morace, Giancarlo Di Gennaro, Angelo Picardi, Liliana G. Grammaldo, Giulio Nicolò Meldolesi, Pier Paolo Quarato, Antonino Raco, Vincenzo Esposito
2006 Neurosurgical Focus  
PILEPTIC seizures are the most common presenting symptom of supratentorial CMs, occurring in up to 70% of patients. 2, 10, 17, 23, 29 The clinical profile of these patients varies widely, ranging from sporadic seizures that are well controlled by medical therapy to drug-resistant focal epilepsy. A high frequency and long history of seizures have been recognized as the most important factors favoring the development of drug resistance. 5, 8, 18 The optimal surgical strategy for treating
more » ... r treating drug-resistant focal epilepsy due to cavernomas is still an open issue. Both lesionectomy (removing the surrounding hemosiderin and gliotic ring or leaving it in place) and tailored resection after invasive EEG recording have been proposed, with controversial results. 18, 25, 31 Caution should be used in comparing different studies, because there are many disparities in definitions of drug resistance, presurgical protocols, resective treatment, and postoperative seizure outcome assessment. Moreover, the patients included in the published case series were often not homogeneous in terms of the kind of focal epileptic syndrome and epilepsy severity. The studies support the suggestion that the seizure outcome following removal of the cavernoma is much better in patients with less severe epilepsy. Although nearly 95% of patients with a short history of epilepsy and rare attacks were seizure free after lesionectomy alone, 50 to 73% of Object. Supratentorial cavernous angiomas may be associated with drug-resistant focal epilepsy. Surgical removal of the malformation may result in seizure control in a number of patients, although in most studies a long history and high frequency of attacks have been recognized as indicators of unfavorable seizure outcome. In the literature, there are no clear indications regarding the optimal diagnostic presurgical workup and the surgical strategy for this particular subgroup of patients with symptomatic epilepsy. In this paper the authors focus on the preoperative workup and the surgical management of the disease in eight consecutive patients undergoing surgery for drug-resistant temporal lobe epilepsy (TLE) due to cavernous malformations (CMs), and the relevant literature on this issue is also reviewed. Methods. Preoperatively, all patients were assessed using a noninvasive protocol aimed at localizing the epileptogenic zone on the basis of anatomical, electrical, and clinical criteria. The presurgical assessment yielded an indication for lesionectomy in two cases, lesionectomy plus anteromesial temporal lobectomy in four cases, and lesionectomy plus extended temporal lobectomy in two cases. At follow-up examinations, seizure, neuropsychological, and psychiatric outcomes were all evaluated. Seven patients were categorized in Engel Class IA (seizure free), and one was categorized in Engel Class IB (occasional auras only). No adverse effects on neuropsychological or psychosocial functioning were observed. Conclusions. Epilepsy surgery can be performed with excellent results in patients with intractable TLE caused by CMs. Noninvasive presurgical evaluation of these patients may enable a tailored approach, providing complete seizure relief in most cases. KEY WORDS • cavernous malformation • drug resistance • seizure • temporal lobe epilepsy • epilepsy surgery 1 Abbreviations used in this paper: AED = antiepileptic drug; AMTL = anteromesial temporal lobectomy; CM = cavernous malformation; EEG = electroencephalography; MR = magnetic resonance; TLE = temporal lobe epilepsy. E
doi:10.3171/foc.2006.21.1.9 pmid:16859261 fatcat:yhl4kwef75h37l7k2qaeoootzm