Excellent Seizure Control Research Articles

Medium‐chain triglyceride (MCT) ketogenic therapy

The medium-chain triglyceride diet (MCTD) is a variant of the classic 4:1 ketogenic diet (KD) introduced in 1971 by Huttenlocher as an attempt to improve the palatability of the KD by allowing more carbohydrates yet preserving ketosis. Although initially found to be equally effective as the classic KD, use of the MCTD declined because of frequent gastrointestinal side effects such as cramps, diarrhea, and vomiting. Recently, we have used the MCTD in more than 50 patients. We have found excellent seizure control, similar to the classic KD, and with careful monitoring, we have encountered minimal side effects. The MCTD should remain a viable dietary option for children with refractory epilepsy who have large appetites, can tolerate more calories, or cannot accept the restrictions of the classic KD.

Stigma of Epilepsy

Epilepsy directly affects 50 million people worldwide. Most can achieve excellent seizure control; however, people living with epilepsy continue to suffer from enacted or perceived stigma that is based on myths, misconceptions and misunderstandings that have persisted for thousands of years. This paper reviews the frequency and nature of stigma toward epilepsy. Significant negative attitudes prevail in the adolescent and adult public worldwide leading to loneliness and social avoidance both in school and in the workplace. People with epilepsy are often wrongly viewed as having mental health and antisocial issues and as being potentially violent toward others. Twenty-five percent of adults having epilepsy describe social stigma as a result of their epilepsy. They fear rejection and often feel shame or loneliness from this diagnosis. The psychosocial and social impact of epilepsy is significant. Yet few specific interventions have been demonstrated to alter this perception. The effect on public education is primarily short-term, while change over the long-term in attitudes and inaccurate beliefs have not presently been proven effective. School education programming demonstrates improved knowledge and attitude a month after a classroom intervention, but persisting change over a longer period of time has not been evaluated. In-depth adult psycho-educational programs for adults with epilepsy improves knowledge, coping skills and level of felt stigma. However these gains have not demonstrated persistence over time. Myths, misconceptions and misunderstandings about epilepsy continue and programs aimed at increasing knowledge and reducing negative public attitudes should be enhanced.

GENERAL SCIENTIFIC SESSION II

INTRODUCTION: Cavernous hemangiomas associated with epilepsy present an interesting surgical dilemma as to whether one should consider pure lesionectomy or tailored resection, especially in the temporal lobe given the potential for cognitive risk. This decision is often guided by electrocorticography (ECoG), despite the lack of data regarding its value in cavernoma surgery. The purpose of this study is several-fold: 1) to determine the epilepsy outcome after cavernoma resection in all brain regions, 2) to evaluate the usefulness of ECoG in guiding surgical decision making, and 3) to determine the optimum surgical approach for temporal lobe cavernomas. METHODS: One hundred and five of 173 patients undergoing surgical resection of cavernomas identified from our surgical database presented with epilepsy, with 61 harboring temporal lobe cavernomas. All patients were evaluated preoperatively by an epileptologist. Mean follow-up period was 37 months. RESULTS: Regardless of cavernoma location, surgery resulted in an excellent seizure control rate Engel Class I of 88% at 2 years. Of the 61 temporal lobe cavernomas, 35 involved the mesial structures. In the temporal lobe cavernomas, patients who had ECoG typically had a more extensive parenchymal resection than lesionectomy (P < 0.001). The use of ECoG in temporal lobe cavernomas resulted in a superior seizure-free outcome of 79% (n = 29) versus 91% (n = 23) at 6 months; 77% (n = 22) versus 90% (n = 20) at 1 year, and 79% (n = 14) versus 83% (n = 18) at 2 years for no ECoG versus ECoG, respectively. CONCLUSION: Surgical resection of cavernomas most often leads to an excellent epilepsy outcome. In temporal lobe cavernomas, the larger the resection as guided by ECoG, the better the seizure outcome. In addition to supporting the concept of kindling, this data advocates the use of ECoG for temporal lobe cavernoma surgery in patients presenting with epilepsy.

Late side-effects of valproate and lamotrigine

Lamotrigine (LTG) is a generally well-tolerated antiepileptic drug with broad-spectrum efficacy in several forms of partial and generalized epilepsy. Adverse effects of lamotrigine are usually associated with introduction and titration. This risk increases in children and in the co-medication with valproate. Herein, we report four patients with late adverse-effects, under the co-medication valproate and LTG, not related to drug introduction or titration. This study demonstrates that late side-effects without apparent etiology in children, adolescents and adults in chronic use of LTG, especially when associated to VPA, led to a diagnostic investigation, sometimes invasive. It must be emphasized that, due to the excellent seizure control, the authors opted for drug decrease instead of drug withdrawal, as previously done. Studies on late adverse effects are scarce, but physicians must be aware of these risks.

Home-Guided Use of the Ketogenic Diet in a Patient for More Than 20 Years

A 26-year-old man with tuberous sclerosis complex and multifocal seizures presented to the ketogenic diet clinic for management of his epilepsy. He had been started on the ketogenic diet at another institution at age 6 years, and his family had managed all nutritional aspects for the previous 10 years. Despite the lack of ongoing medical care, excellent seizure control and large urinary ketosis had been maintained, and side effects were limited only to poor growth. He remains on the diet to date, now for 21 years of continuous duration.

Clinical features and surgical outcome of patients with indolent brain tumors and epilepsy

INTRODUCTION: In this study the authors review the outcomes of 22 patients with medically refractory epilepsy and slow growth brain tumors. OBJECTIVES: Evaluate the clinical, electrophysiological, operative, and histopathological features. PATIENTS AND RESULTS: The majority of the tumors were located in the temporal lobe (n = 20) and involved the cortical gray matter. The most frequent tumors were gangliogliomas (n = 9), astrocytomas grade I and II (n = 6), dysembryoplastic neuroepithelial tumors (n = 5) and ganglioneuroma (n = 2). The biological behavior of the tumors was strikingly indolent, as indicated by a long preoperative history of chronic seizures (mean, 14 years). Mean follow-up time after resection was 27 months, and according to Engel’s classification, 85% were seizure-free, 10% showed a reduction of seizure frequency of at least 90%, and 5% had reduction in seizure frequency at least 75%. CONCLUSION: The data indicate that neoplasms associated with pharmacoresistent epilepsy constitute a distinct clinicopathological group of tumors that arise in young patients, involve the cortex, and exhibit indolent biological behavior for many years. Complete surgical removal of these tumors, including the epileptogenic area, can achieve excellent seizure control.

Hemispherectomy for intractable epilepsy in adults: The first reported series

Hemispherectomy for intractable unihemispheric epilepsy (IUE) has long been established in pediatric patients. This study reports the first series examining hemispherectomy exclusively in adult patients (>18 years old). Nine adults with IUE underwent hemispherectomy at the University of Minnesota. All patients had unilateral hemiplegia and visual field loss. Seven patients (77.8%) were Engel class I/II at last follow-up. Five (83.3%) of the six patients with >30 years of follow-up were seizure free. No surgery-related mortality, hydrocephalus, or superficial cerebral hemosiderosis occurred. Hemispherectomy is an effective procedure in appropriately selected adult patients, resulting in excellent long-term seizure control and no mortality.

Clinical science

Abstract Ognen A. C. Petroff, Fahmeed Hyder, Douglas L. Rothman, and Richard H. Mattson Yale researchers in pioneering work have been able to study the effects of antiepileptic drugs (AEDs) on the brain chemistry of people with epilepsy in a safe and painless manner by using the principles of magnetic resonance imaging (MRI). Neurons in the human brain make homocarnosine from γ-aminobutyric acid (GABA; the brain's main inhibitory neurotransmitter) and histidine in larger amounts than the neurons of almost all other animals. Three of the newer AEDs, gabapentin (GBP; Neurontin), topiramate (TPM; Topamax), and vigabatrin (Sabril), increase human homocarnosine levels. We measured homocarnosine and GABA levels of 20 patients with complex partial seizures taking GBP and 17 patients taking TPM. Homocarnosine levels were higher in patients with better seizure control than in those whose seizure control was below the middle value (median) for the two groups. No differences were found in the GABA levels between the patients, who showed a better response to GBP or TPM, compared with those who did not. Higher homocarnosine levels (above the median) were associated with better seizure control in the patients taking GBP or TPM; higher brain GABA levels appeared to offer no additional protection. The current results are similar to our previously published findings, which showed higher brain homocarnosine levels in patients with juvenile myoclonic epilepsy with excellent seizure control, taking valproate (Depakote) or lamotrigine (Lamictal), than the levels of patients with more frequent seizures. The data support the hypothesis that increased homocarnosine and GABA levels contribute to the anticonvulsant properties of GBP and TPM, perhaps by limiting the spread of seizures from the areas where seizures start.

Frequent association of cortical dysplasia in dysembryoplastic neuroepithelial tumor treated by epilepsy surgery

Background We report on our experience with epilepsy surgery in the treatment of localization-related epilepsy caused by dysembryoplastic neuroepithelial tumor (DNT) aimed at achieving the best seizure control. Methods A retrospective analysis was performed on the pathological reports as well as on clinical data of 24 case patients with medically intractable epilepsy with DNT treated surgically between 1995 and 2000 at the Samsung Medical Center. Resective surgery was performed using subdural electrodes or intraoperative electrocorticography in all patients. Results The mean follow-up period was 57.2 months. Two patients had rare seizures transiently after surgery but remained free from seizures after 6 months. Others remained completely free from seizures. There was a strong tendency of temporal lobe involvement (19 cases; 79.2%). Size of tumors located at medial temporal regions was significantly smaller than those at lateral temporal or frontal lobes ( P < .05). A rather radical resection (tumor plus surrounding tissue showing active epileptogenicity) was performed in all but one case where only focal lesionectomy was done. In 20 of the 24 cases (83.3%), association of cortical dysplasia (CD) was found on pathological examination. Conclusions We conclude that DNT is frequently associated with CD, with a wide area of epileptogenic activity that might be related to the presence of CD around the DNT. Comprehensive preoperative investigations for accurate localization of epileptogenic activity, meticulous brain mapping, and a rather radical resection of pathological areas might be essential for the achievement of excellent seizure control in DNT-associated epilepsy.

Efficacy of Levetiracetam at 12 Months in Children Classified by Seizure Type, Cognitive Status, and Previous Anticonvulsant Drug Use

In a retrospective study of 59 children (ages 9 months to 23 years; mean age 11 years) with intractable epilepsy, seizure frequency was determined before and after 12 months of levetiracetam therapy. Charts were reviewed for seizure type (focal, generalized, or mixed), cognitive function (no special education versus special education), concomitant anticonvulsant medications (range 0-5), and the number of previous anticonvulsant drugs (range 1-12). Good to excellent seizure control (50-100% reduction) was attained in 6 (40%) patients with focal seizures, 16 (55%) patients with generalized seizures, and 8 (61%) patients with mixed seizures; these efficacy rates were not significantly different. The efficacy of levetiracetam was independent of cognitive status. Adverse effects were not associated with higher mean doses. This could be attributable to different rates of metabolism or represent idiosyncratic responses to the medication. Our finding that those children taking the combination of levetiracetam and zonisamide had a significantly worse outcome than those on levetiracetam and a different drug warrants further study, both clinically and from the standpoint of the mechanisms of action of levetiracetam and zonisamide and/or their pharmacodynamic interactions.

Broad-Spectrum Efficacy of Zonisamide at 12 Months in Children With Intractable Epilepsy

In a retrospective study of 35 children (ages 8 months to 22 years; mean age 9 years) with intractable epilepsy, seizure frequency was determined before and after 12 months of zonisamide therapy. Charts were reviewed for seizure type (focal, generalized, or mixed), cognitive function (no special education versus special education), concomitant anticonvulsant medications, and the number of previous anticonvulsant drugs. Good to excellent seizure control (50-100% reduction) was attained in seven (54%) patients with generalized seizures, two (40%) patients with focal seizures, five (35%) patients with mixed seizures, and one (33%) patient with infantile spasms. In this group of children, the efficacy of zonisamide was comparable for focal, generalized, and mixed seizures. The efficacy of zonisamide was independent of cognitive status. Adverse effects were not associated with a higher mean dose. This could be attributable to different rates of metabolism or represent idiosyncratic responses to the medication. Our finding that those children taking the combination of zonisamide and levetiracetam had a significantly worse outcome than those on levetiracetam and a different drug warrants further study, both clinically and from the standpoint of mechanisms of action of zonisamide and levetiracetam and/or their pharmacodynamic interactions.

Epileptogenic foci on subdural recording in intractable epilepsy patients with temporal dysembryoplastic neuroepithelial tumor.

To investigate the epileptogenic foci in dysembryoplastic neuroepithelial tumor (DNT) in the temporal lobe, we studied extraoperative electrocorticography (ECoG) with subdural electrode arrays from nine patients with intractable epilepsy due to temporal DNT. Ictal onset zones and irritative zones were decided by the ECoG. The locations of these zones were compared to the location of the tumor. The number of ictal onset zone and irritative zone was 2.1+/-0.93 and 2.9+/-1.45 in a patient with a DNT. They were detected more frequently in the adjacent tissues of the tumor (88.9%) rather than within the tumor or in mesial temporal area (66.7%). Mesial temporal involvement was found in 6 patients (66.7%) as an ictal onset zone, and in 5 (55.6%) as an irritative zone. The 7 patients (77.8%) had ictal onset zone in areas different from active irritative zone. The surgical outcome was better, when ictal onset zone was completely resected rather than partially removed. Temporal DNT can make multiple ictal onset zones and irritative zones in different regions including the mesial temporal area. Deliberate resection of epileptogenic foci, including all ictal onset zones and irritative zones, ensures excellent seizure control.

Factors predictive of suboptimal seizure control following selective amygdalohippocampectomy.

Selective amygdalohippocampectomy (SelAH) is used in the treatment of mesial temporal lobe epilepsy (MTLE). The goal of this study was to determine factors predictive of poor postoperative seizure control (Engel Class III or IV) following SelAH. A retrospective study was conducted of 27 patients with poor seizure control postoperatively (Engel III/IV group), in comparison with 27 patients who were free from seizures after surgery (Engel I/II group). The results of electroencephalography, magnetic resonance (MR) imaging, and pathological studies were reviewed, and volumetric MR image analysis was used to compare the extent of the mesial structures that had been resected. In 56% of patients in the Engel III/IV group, significant bitemporal abnormalities were displayed on preoperative EEG studies, compared with 24% of patients in the Engel I/II group (p < 0.05). An analysis of preoperative MR images disclosed five patients (19%) in the Engel III/IV group and no patient in the Engel I/II group with normal hippocampal volumes bilaterally. Thirteen patients in the Engel III/IV group subsequently underwent either extension of the SelAH (six cases) or a corticoamygdalohippocampectomy (seven patients). Three patients from the former and one patient from the latter subgroup subsequently became seizure free (four patients total [34%]). The remaining nine patients did not improve despite the fact that they had undergone near-total resection of mesial structures. The majority of patients receiving suboptimal seizure control following SelAH did not meet the criteria for unilateral MTLE, based on EEG, MR imaging, and/or histopathological studies. These patients were therefore unlikely to benefit from additional resection of mesial structures. With the benefits of modern imaging, and by strict adherence to selection criteria, SelAH can be predicted to yield excellent postoperative seizure control for nearly all patients with unilateral MTLE. There remains a subpopulation, however, that meets the criteria for MTLE, but does not become free from seizure following SelAH.

Focal ictal beta discharge on scalp EEG predicts excellent outcome of frontal lobe epilepsy surgery.

To determine whether a focal beta-frequency discharge at seizure onset on scalp EEG predicts outcome of frontal lobe epilepsy (FLE) surgery. We identified 54 consecutive patients with intractable FLE who underwent epilepsy surgery between December 1987 and December 1996. A blind review of EEGs and magnetic resonance images (MRIs) was performed. Lesional epilepsy is defined as presence of an underlying structural abnormality on MRI. Overall, 28 (52%) patients were seizure free, with a mean follow-up of 46.5 months. Presence of a focal beta-frequency discharge at seizure onset on scalp EEG predicted seizure-free outcome in lesional (p = 0.02) and non-lesional (p = 0.01) epilepsy patients. At least 90% of patients who had either lesional or non-lesional epilepsy were seizure free if scalp EEG revealed a focal beta discharge at ictal onset. Moreover, logistic regression analysis showed that focal ictal beta pattern and completeness of lesion resection were independently predictive of seizure-free outcome. Ictal onset with lateralized EEG activity of any kind and postresection electrocorticographic spikes did not predict surgical outcome (p > 0.05). Only about 25% of FLE surgical patients have a focal beta-frequency discharge at seizure onset on scalp EEG. However, its presence is highly predictive of excellent postsurgical seizure control in either lesional or non-lesional FLE surgical patients.

Ictal ECD-SPECT differentiates between temporal and extratemporal epilepsy: confirmation by excellent postoperative seizure control.

We investigated whether ictal single photon emission computed tomography (SPECT) with 99Tcm-ethyl cysteinate dimer (ECD) could differentiate between temporal (TE) and extratemporal epilepsy (ETE) in 30 consecutive patients (n = 21 for TE, n = 9 for ETE), all of whom had excellent postoperative seizure control (class I according to Engel's classification). Ictal SPECT showed isolated temporal hyperperfusion in 90% (19 out of 21) of the TE patients and normal perfusion in two patients. All the ETE patients had ictal SPECT findings consistent with extratemporal seizure onset. The sensitivity of ictal ECD-SPECT for correct localization of the seizure onset zone was 80% in all patients, 86% in TE patients and 66% in ETE patients. Although ictal ECD-SPECT has a lower sensitivity in ETE than in TE, it can be used to clearly distinguish between TE and ETE. It provides non-invasive imaging information for use in further diagnostic and treatment strategies in patients with drug-resistant focal epilepsy.

Surgical treatment of intractable epilepsy accompanying cortical dysplasia.

Surgical treatment of cortical dysplasia (CD) together with intractable seizures is challenging because both visualization and localization of the lesion are difficult, correlation with seizure foci requires comprehensive study, and the surgical outcomes reported thus far are unsatisfactory. The authors report their experience in the surgical treatment of CD classified according to a surgical point of view. The definition of CD used in this study was a dysplastic lesion visible on magnetic resonance (MR) images or a lesion that, although not visible on MR images, was diagnosed as moderate-to-severe dysplasia by using pathological analysis. During the last 4.5 years, the authors treated 36 patients with intractable epilepsy accompanied by CD. They divided the 36 cases of CD into four characteristic groups: Group A, diffuse bilateral hemispheric dysplasia; Group B, diffuse lobar dysplasia; Group C, focal dysplasia; and Group D, a moderate to severe degree of CD with a normal appearance on MR images. All but one patient in Group C were monitored in the epilepsy monitoring unit by using subdural electrodes for seizure localization and functional mapping. The incidence of CD among a cohort of 291 patients who had undergone epilepsy surgery at the authors' center during the study period was 12.4%. The mean age of the 36 patients was 21.3 years and the mean age at seizure onset was 8.5 years. The mean follow-up period was 26 months. Twenty-six patients (72.2%) belonged to Engel Class I or II (20 and six, respectively). There were five cases in Group A, nine in Group B, nine in Group C, and 13 in Group D. Patients in Groups A and B were significantly younger at seizure onset and had significantly poorer surgical outcomes compared with patients in Groups C and D (p < 0.05). If outcome is compared on the basis of the extent of removal of CD, patients in whom CD was completely removed had significantly better outcomes than those in whom CD was only partially removed (p < 0.001). The authors conclude that intractable epilepsy accompanied by CD can be treated surgically using comprehensive preoperative approaches. Deliberate resective procedures aimed at complete removal of dysplastic tissue ensure excellent seizure control without permanent neurological deficit.

Usefulness of Neuroimaging Studies for Localization of the Epileptogenic Focus in Patients with Frontal Lohe Epilepsy Manifesting as Complex Gestural Automatisms

Purpose: The goal of this study was to evaluatc the usefulness of ncuroimaging studies for localization of thc epileptogenic focus in patients with frontal lobe epilepsy (FLE). The clinical manifestations werc complex partiel seizures, characterizedd by kicking and thrashing, groaning, occurrence in clusters, being brief (lasting for &lt;40 seconds), and cnding with minimal postictal confusion. Methods: Thc subjects werc 7 patients, aged 1040 ycars (mean agc, 24.3), with complex partial seizurcs, undergoing preoperative evaluations for intractable seizures. All seizurcs wcre documcuted as conforming to complcx geslural automatism by simultaneous EEG‐VCR recordings. We asscssed the clinical features, interictal and ictal electroencephalograms (EEGs), and results of magnetic resonance imaging (MRI), and interictal PVTc ethyl cysteinate dimcr (ECD) singlc photon emission computed tomography (SPECT). Additionally, we studied ictal ECD SPECT findings in 4 patients. We compared the usefulness of EEG, MRI, and SPECT for localization of thc cpileptogenic focus. Results: Thc patients comprised 6 nialcs and I female. The agc at seizurc onset was 1–25 years (mcan, 10.5). One patient had a family history of febrilc seizures and another of anoxia at birth. One patient had a history of ideas of persecution and refercnce. The results of neuropsychological evaluation revealed that their full intelligence quoticnt varied from 51–1 I I (mcan 88). Seizure frequencics at initial consultation varied from monthly to daily in thc 7 patients. Thrce of the 7 patients undcrwent surgical resection of the fronial lobe, and 2 of the 3 became frce of the intractable scizures. lnterictal dischargc such as spikcs or sharp waves were localized at F3 in 2 patients and at F4 in 5 patients. Ictal discharge at the onset of a paltcrn in scalp EEG recordings in 2 pati waves wcre seen at the left frontal lobe in I bilaterally in patient. The ictal scalp EEG recordings of the remaining 3 patients were distorted by electromyographic and movement artifacts. Finally, it was determined that the ictal scalp EEG is not always helpful for the localization of the epileptogenic focus. MRI revcaled focal cortical dysplasia in 2 patients: in the right middle frontal gyrus in I, and left basolateral frontal lobe i n the other. Interictal ECD SPECT revealcd no hypoperfused area in any of the 7 paticnts. We obtained ictal ECD SPECT i n 4 paticnts in cooperation with colleagues who controlled the violent movements of the patient during a seizure. In all 4 cases, ictal ECD SPECT revealed hypcrperftision in the frontal lobe, in the left frontal area in 2 patients and the right frontal area in 2 patients. Three of the 4 patients had undergone epilepsy surgery. Thc 2 patients who had cortical dysplasia underwent cxcision of the lesion and had excellent seizure control. The remaining I paticnt who had no abnormal CT findings continued to have seizures wcckly even after resection of the right orbitofrontal cortex. Conclusions: It is difficult to localize the epileptogenic focuin cases of complex gcstural automatism. The diagnostic yield in our study was maximal with ictal ECD SPECT even though thc seizure pattern could not be diagnosed clearly due to interference by electromyographic waves. A combination of MRI and ictal ECD SPECT is the key to localization of the cpileptic focus in casc of FLE with complex gestural automatism.

Predictors of outcome of anterior temporal lobectomy for intractable epilepsy: a multivariate study.

To identify presurgical and postsurgical factors that are independently predictive of the outcome of anterior temporal lobectomy (ATL) for intractable epilepsy. There have been reports of prognostic factors in epilepsy surgery, but little is known about factors that independently predict outcome of ATL. We studied 175 consecutive ATL patients who had at least 2 years of postsurgical follow-up. Significant factors on univariate analyses were subjected to stepwise logistic regression analysis. On univariate analyses, two presurgical conditions were significantly associated with excellent seizure control at last follow-up: (1) unilateral hippocampal formation atrophy as detected on MRI and (2) all scalp interictal epileptiform discharges concordant with the location of ictal onset (p < 0.05). Three postsurgical factors that occurred during the first year were associated with excellent seizure outcome: the absence of interictal epileptiform discharges at 3 months, complete seizure control, and having only nondisabling seizures for those who did not become seizure free. Logistic regression analysis revealed the following to be independently predictive of excellent seizure control: MRI-detected unilateral hippocampal formation atrophy, concordant interictal epileptiform discharges, complete seizure control during the first postsurgical year, and having only nondisabling seizures during the first postsurgical year for those who did not become seizure free. Presurgical identification of unilateral hippocampal formation atrophy, or of interictal epileptiform discharges that are all concordant with the location of ictal onset, predict excellent outcome of ATL. However, the probability of excellent outcome is highest (94%) when both factors are present.

Factors Associated with Work Outcome After Anterior Temporal Lobectomy for Intractable Epilepsy

Whereas the effect of anterior temporal lobectomy on seizure frequency is well recognized, less is known about its impact on work status. One hundred thirty-four of 190 consecutive patients with temporal lobectomy participated in this study. Eligibility criteria were developed to ensure that only patients with the potential of achieving specific outcomes were included in the corresponding analyses. After surgery, significantly more patients were independent in activities of daily living (p < 0.001) or able to drive (p < 0.001). Income from work also increased (p < 0.01). Nearly one fifth of the patients who were eligible for analysis had either a gain (8%) or a loss (11%) of full- or of part-time work. Univariate analyses revealed the following factors to be associated with full-time work after surgery: student or full-time work within a year before surgery, full-time work experience before surgery, full- or part-time employment experience before surgery, no disability benefits before surgery, low postsurgical seizure frequency, improved postsurgical seizure control, excellent postsurgical seizure control, driving after surgery, and further education after surgery (p < 0.05). Significant factors on multivariate analysis were being a student or having full-time work within a year before surgery [odds ratio, 16.2 (95% CI, 4.3-60.5)], driving after surgery [15.2 (3.2-72.0)], and obtaining further education after surgery [9.2 (2.2-53.0)]. Anterior temporal lobectomy for intractable epilepsy improves activities of daily living and the ability to drive. Work outcome of this surgery is influenced by presurgical work experience, successful postsurgical seizure control especially to allow driving, and obtaining further education after surgery.

Post-traumatic frontal lobe epilepsy with structural changes: excellent results after cortical resection.

The observation that resection of structural lesions of the frontal lobe provides an effective treatment of intractable epilepsy has been made by surgeons specializing in this field for over sixty years! However, the excellent results achieved when such resections are coupled with the use of modern diagnostic and operative technologies are not fully appreciated by the modern clinician. We review the results of resection of large post traumatic frontal lesions in six patients with intractable frontal seizures. No invasive EEG recording was required pre-operatively. The imaging characteristics of the underlying lesions, usually due to depressed skull fractures are illustrated. Surgical treatment rendered five patients seizure free and the sixth had over 85% improvement in seizure frequency. Modern imaging permits ready visualization of the post traumatic lesions with cause intractable seizures. It is important to recognize that resection of these post traumatic scars usually leads to excellent seizure control.