Frontal Lobe Epilepsy Surgery Research Articles

Electrocorticographic Patterns in Frontal Epilepsy and Long-Term Outcomes [RETRACTED

The prognostic significance of tailored resection guided with intraoperative electrocorticography (iECoG) in frontal lobe epilepsy surgery has not been fully elucidated. To analyze influence of preresection and postresection iECoG patterns on long-term seizure control of adults with frontal lobe epilepsy undergoing epilepsy surgery. We retrospectively analyzed 27 patients undergoing epilepsy surgery from two centers with preresection and postresection iECoG and reported clinical variables, preresection and postresection iECoG patterns, and outcome using the Engel Outcome Scale. Descriptive statistics, Kaplan-Meier, the logistic regression model, and analysis of variance tests were used. Fifteen males (55.6%), a mean and mode follow-up after surgery of 43 (range 2-117) and 19 months, respectively. At 6 months, seizure frequency outcome according to Engel Scale was I 74.1% (20/27), II 7.4% (2/27), III 3.7% (1/27), and IV 14.8% (4/27). We found that 51.9% (14/27) and 40.8% (11/27) of patients without residual epileptiform discharges in postresective iECoG become seizure-free at 6 and 12 months of follow-up, respectively, compared with other postresective iECoG patterns. Disregarding the presence of lack of residual epileptiform discharges (interictal epileptiform discharges) after resection, Engel I outcome was seen between 74.1% and 63% at 6- and 12-month postresection follow-up, suggesting the outcome might be in relation with other factors.

Thalamostriatal disconnection underpins long-term seizure freedom in frontal lobe epilepsy surgery.

Around 50% of patients undergoing frontal lobe surgery for focal drug-resistant epilepsy become seizure free post-operatively; however, only about 30% of patients remain seizure free in the long-term. Early seizure recurrence is likely to be caused by partial resection of the epileptogenic lesion, whilst delayed seizure recurrence can occur even if the epileptogenic lesion has been completely excised. This suggests a coexistent epileptogenic network facilitating ictogenesis in close or distant dormant epileptic foci. As thalamic and striatal dysregulation can support epileptogenesis and disconnection of cortico-thalamostriatal pathways through hemispherotomy or neuromodulation can improve seizure outcome regardless of focality, we hypothesize that projections from the striatum and the thalamus to the cortex may contribute to this common epileptogenic network. To this end, we retrospectively reviewed a series of 47 consecutive individuals who underwent surgery for drug-resistant frontal lobe epilepsy. We performed voxel-based and tractography disconnectome analyses to investigate shared patterns of disconnection associated with long-term seizure freedom. Seizure freedom after 3 and 5 years was independently associated with disconnection of the anterior thalamic radiation and anterior cortico-striatal projections. This was also confirmed in a subgroup of 29 patients with complete resections, suggesting these pathways may play a critical role in supporting the development of novel epileptic networks. Our study indicates that network dysfunction in frontal lobe epilepsy may extend beyond the resection and putative epileptogenic zone. This may be critical in the pathogenesis of delayed seizure recurrence as thalamic and striatal networks may promote epileptogenesis and disconnection may underpin long-term seizure freedom.

Value of semiology in predicting epileptogenic zone and surgical outcome following frontal lobe epilepsy surgery

ObjectiveTo evaluate the ability of semiology alone in localising the epileptogenic zone (EZ) in people with frontal lobe epilepsy (FLE) who underwent resective surgery. MethodsWe examined data on all individuals who had FLE surgery at our centre between January 01, 2011 and December 31, 2020. Descriptions of ictal semiology were obtained from video-EEG telemetry reports and presurgical multidisciplinary meeting summaries. The putative EZ was represented by the final site of resection. We assessed how well initial and combined set-of-semiologies correlated anatomically with the EZ, using a semiology visualisation tool to generate probabilistic cortical heatmaps of involvement in seizures. ResultsSixty-one individuals had FLE surgery over the study period. Twelve months following surgery, 28/61 (46%) were completely seizure-free, with a further eight experiencing only auras. Comparing the semiology database with the putative EZ, combined set-of-semiology correctly lateralised in 77% (95% CI: 69–85%), localised to the frontal lobe in 57% (95% CI: 48–67%), frontal lobe subregions in 52% (95% CI: 43–62%), and frontal gyri in 25% (95% CI: 16–33%). No difference in degree of correlation was seen comparing those with ongoing seizures 12 months after surgery to those seizure free. SignificanceSemiology alone was able to correctly lateralize the putative EZ in 77%, and localise to a sublobar level in approximately half of individuals who had FLE surgery. Semiology is not adequate alone and must be combined with imaging and EEG data to identify the epileptogenic zone.

Long-term seizure, psychiatric and socioeconomic outcomes after frontal lobe epilepsy surgery

ObjectiveResective surgery for selected individuals with frontal lobe epilepsy can be effective, although multimodal outcomes are less established than in temporal lobe epilepsy. We describe long-term seizure remission and relapse patterns, psychiatric comorbidity, and socioeconomic outcomes following frontal lobe epilepsy surgery. MethodsWe reviewed individual data on frontal lobe epilepsy procedures at our center between 1990 and 2020. This included the presurgical evaluation, operative details and annual postoperative seizure and psychiatric outcomes, prospectively recorded in an epilepsy surgery database. Outcome predictors were subjected to multivariable analysis, and rates of seizure freedom were analyzed using Kaplan-Meier methods. We used longitudinal assessment of the Index of Multiple Deprivation to assess change in socioeconomic status over time. ResultsA total of 122 individuals with a median follow-up of seven years were included. Of these, 33 (27 %) had complete seizure freedom following surgery, with a further 13 (11 %) having only auras. Focal MRI abnormality, histopathology (focal cortical dysplasia, cavernoma or dysembryoplastic neuronal epithelial tumor) and fewer anti-seizure medications at the time of surgery were predictive of a favorable outcome; 67 % of those seizure-free for the first 12 months after surgery never experienced a seizure relapse. Thirty-one of 50 who had preoperative psychiatric pathology noticed improved psychiatric symptomatology by two years postoperatively. New psychiatric comorbidity was diagnosed in 15 (13 %). Persistent motor complications occurred in 5 % and dysphasia in 2 %. No significant change in socioeconomic deciles of deprivation was observed after surgery. SignificanceFavorable long-term seizure, psychiatric and socioeconomic outcomes can be seen following frontal lobe epilepsy surgery. This is a safe and effective treatment that should be offered to suitable individuals early.

Surgical treatment of pediatric intractable frontal lobe epilepsy due to malformation of cortical development

BackgroundMalformation of cortical development (MCD) is a common cause of intractable epilepsy in children. In this study, the effectiveness of frontal lobe epilepsy (FLE) surgery in children with intractable epilepsy due to MCD was assessed and its prognostic factors were studied.MethodsSeventy-six patients with intractable FLE who received epilepsy surgery between January 2016 and March 2018 in Peking University First Hospital were recruited in this study. All the resected brain tissues were demonstrated to be MCD. All patients were followed up for at least 3 years. The clinical data and prognosis were analyzed retrospectively. Univariate and multivariate analyses were performed to investigate the correlations between clinical variables and prognostic outcome (Engel classification).ResultsSixty (78.9%) patients had Engel class I postoperative outcome. The mean age at surgery was 6.00 ± 4.24 years. Sixty-six patients (86.8%) had daily seizures, 40.2% of the patients had epileptic spasm, and 33% of the patients had extensive interictal EEG abnormalities, which, however, could not provide any helpful information for localizing epileptogenic zones. About 29% of the patients had normal MRI findings even by experienced radiologists, and 26% of the patients had epileptogenic lesion involving adjacent lobes. There was a significant correlation between acute postoperative seizure (APOS) and prognosis (P < 0.05): APOS predicted poor prognosis. There was a significant correlation between pathology and prognosis (P < 0.05): FCD IA and FCD IIB were correlated with a good outcome. Both variables with a significance level of P < 0.05 during univariate analysis, including pathology and APOS, were included in multivariate analysis, which were significant independent predictors of prognosis.ConclusionsThe clinical manifestations of pediatric intractable FLE due to MCD are more complicated than those in adults. Multidisplinary presurgical evaluation in pediatric epilepsy is mandatory. The surgical outcome of pediatric FLE due to MCD could reach a seizure-free rate of 78.9% with the follow-up of at least 3 years. The post-operative pathology and APOS may be related to the prognosis of surgery in this group of pediatric patients.

Prediction of Quality of Life after Surgery for Frontal Lobe Epilepsy by Neuropsychological Assessments

Prediction of Quality of Life after Surgery for Frontal Lobe Epilepsy by Neuropsychological Assessments

Experiences of emotional and psychosocial functioning after frontal lobe resection for epilepsy

PurposeFrontal lobe resection (FLR) is the second most common epilepsy surgery procedure in adults. Few studies address neuropsychological consequences after FLR. The aim of this study was to explore patients’ and relatives’ experiences of cognitive, emotional and social cognitive functioning after frontal lobe epilepsy surgery. MethodsSemi-structured interviews were held with 14 patients having gone through FLR as adults during the years 2000–2016 and 12 of their relatives. Interviews were audio-recorded, transcribed and analyzed with inductive qualitative content analysis. ResultsPositive as well as negative consequences were described both by patients and relatives. Feelings of relief and an increased capacity to experience emotions of well-being were mainly experienced as related to seizure freedom. A newfound autonomy and a more grown-up identity as opposed to a self-image based on epilepsy was also highlighted. However, results also showed that even for seizure free patients, FLR could give rise to negative experiences, the most prominent of which were mental fatigue, lowered mood and social withdrawal. Coping strategies included planning ahead to avoid mental exhaustion. Over all, respondents considered that the epilepsy surgery had been a risk well worth taking and that positive consequences outweighed the negative ones. ConclusionsThis study shows a range of positive as well as negative outcomes after FLR for epilepsy. The findings indicate that lowered mood and mental fatigue could affect the life situation in a negative way, regardless of seizure outcome. This is important to consider in the preoperative counselling of patients and their families, as well as in the postsurgical follow-up. It is also crucial that the epilepsy surgery team has the possibility to offer rehabilitation and support to families regarding these aspects after surgery.

Seizure outcome and its predictors after frontal lobe epilepsy surgery.

Frontal lobe epilepsy (FLE) surgery is the second most common focal resective surgery for drug-resistant epilepsy. Not many studies are available regarding the long-term surgical outcome of FLE. We studied the longitudinal outcome and predictors of seizure outcome following FLE surgery in a sizeable cohort of patients. A total of 73 consecutive patients who underwent FLE surgery between January 1997 and May 2015 with a minimum follow-up of 1year (range 1-16years) were studied. Primary outcome was seizure freedom at last follow-up (Engel Class IA). "Seizure freedom" separately was defined as absence of seizures till last follow-up. Outcome predictors were subjected to multivariate analysis. Using Kaplan-Meier curve, we assessed the post-operative seizure freedom over time. Twenty-five patients (34%) were seizure-free till last follow-up. The seizure freedom was 45%, 34%, 26%, 20% and 14% at the end of 1st, 2nd, 3rd, 4th and 5th post-operative year, respectively. Engel class I outcomes were 48%, 41%, 56%, 57% and 53% at end of 1st, 2nd, 3rd, 4th and 5th post-operative year, respectively. Predictors of seizure recurrence on multivariate analysis were older age at surgery (P=0.032), longer duration of epilepsy (P=0.031), presence of interictal epileptiform discharges in post-operative EEG on 7th day (P=0.005), 3months (P=0.005) and 1year (P=0.0179). In subgroup analysis, duration of epilepsy of less than 2years before surgery was a significant predictor for achieving seizure freedom (P=0.029). These results emphasize early surgery for better outcome in frontal lobe epilepsy. Post-operative EEG remained a good predictor for long-term outcome.

Long-term seizure outcome in frontal lobe epilepsy surgery

PurposeThe purpose of this study was to report long-term seizure outcome in patients who underwent frontal lobe epilepsy (FLE) surgery. MethodThis retrospective study included 44 consecutive subjects who underwent resective surgery for intractable FLE at IRCCS NEUROMED (period 2001–2014), followed up for at least 2 years (mean: 8.7 years). All patients underwent noninvasive presurgical evaluation and/or invasive electroencephalography (EEG) monitoring when nonconcordant data were obtained or epileptogenic zone was hypothesized to be close to the eloquent cortex. Electroclinical, neuroimaging, surgical data, and histology were compared to seizure outcome. ResultsMean epilepsy duration was 19 years; mean age at surgery was 31.6 years. Preoperative magnetic resonance imaging (MRI) showed a frontal lesion in 86.4 % of cases. Scalp video-electroencephalography (VEEG) monitoring detected a focal ictal onset in 90% of cases. Twenty-seven patients (61.4%) underwent invasive recordings. Resections involved dorsolateral (47.7%), medial (9%), orbital (13.6%), and rolandic (13.6%) region. Lobectomy within functional boundaries was performed in the remaining 7 cases (16%). Transient and permanent neurological deficits were observed in 2 and 3 cases, respectively. Histology revealed focal cortical dysplasia (45.5%), World Health Organization (WHO) I–II grade tumors (15.9%), gliosis (22.7%), vascular malformations (4.5%), Rasmussen encephalitis (6.8%), and normal tissue (4.5%). At last observation 68.1% of patients were in Engel's class I, 11.4% in class II, 9% in class III, and 11.4% in class IV. A favorable outcome was associated with focal ictal scalp EEG onset (p = 0.0357). ConclusionSurgery is a safe treatment option in drug-resistant FLE with a satisfying long-term outcome. These data highlight the importance of an appropriate selection of potential surgical candidates.

Prognostic Factors and Longitudinal Change in Long-Term Outcome of Frontal Lobe Epilepsy Surgery

We aimed to investigate the possible predictive factors and longitudinal change in long-term surgical outcome after refractory frontal lobe epilepsy surgery. We retrospectively reviewed 82 patients who underwent frontal lobe resection. Invasive monitoring was performed in 43 patients. All patients were followed-up for a minimum of 3 years after surgery. Univariate and multivariate analyses were used to evaluate the predictors. The Kaplan-Meier survival curve showed the estimated probability of complete seizure freedom, and a favorable outcome was defined as Engel class I at the last follow-up. The estimated probability of complete seizure freedom was 57.3% at 1 year postoperatively, 51.2% at 2 years, and 50.0% at 5 years. Factors predictive of worse long-term outcome were lack of a lesion in the frontal lobe on magnetic resonance imaging, generalized/nonlocalized ictal discharge, use of subdural grids, and acute postoperative seizure (APOS). After the surgery, 44 patients (53.7%) had seizures at any time during the first 2 years. Five of 44 patients had seizure freedom at the last follow-up. After a seizure-free period of at least 6 months, seizure recurred in 6 patients by 6 months to 1 year (early recurrence) and in 9 patients by 1-3 years (late recurrence). Eight of 43 (18.6%) seizure-free patients had discontinued drugs. The overall seizure outcome after surgery changed most during the first 2 years. The presence of frontal focal lesions and ictal frontal rhythm predicted favorable outcome. However, APOS was predictive of early epilepsy recurrence.

Frontal Lobe Epilepsy Surgery in Childhood and Adolescence: Predictors of Long-Term Seizure Freedom, Overall Cognitive and Adaptive Functioning.

Although frontal lobe resections account for one-third of intralobar resections in pediatric epilepsy surgery, there is a dearth of information regarding long-term seizure freedom, overall cognitive and adaptive functioning. To identify outcome predictors and define the appropriate timing for surgery. We retrospectively analyzed the data of 75 consecutive patients aged 10.0 ± 4.9 yr at surgery that had an 8.1 yr mean follow-up. Etiology comprised focal cortical dysplasia (FCD) in 71% and benign tumors in 16% cases. All patients but one had a magnetic resonance imaging-visible lesion. At last follow-up, 63% patients remained seizure-free and 37% had discontinued antiepileptic drugs. Presurgical predictors of seizure freedom were a shorter epilepsy duration, strictly regional epileptic discharges in electroencephalography (EEG), and an epileptogenic zone and/or lesion distant from eloquent cortex. Postsurgical predictors were the completeness of resection and the lack of early postoperative seizures or epileptic discharges in EEG. Higher presurgical overall cognitive and adaptive functioning was related to later epilepsy onset and to a sublobar epileptogenic zone and/or lesion. Following surgery, scores remained stable in the majority of patients. Postsurgical gains were determined by higher presurgical performance and tumors vs FCD. Our findings highlight the favorable long-term outcomes following frontal lobe epilepsy surgery in childhood and adolescence and underline the importance of early surgical intervention in selected candidates. Early postsurgical relapses and epileptic discharges in EEG constitute key markers of treatment failure and should prompt timely reevaluation. Postsurgical overall cognitive and adaptive functioning is stable in most patients, whereas those with benign tumors have higher chances of improvement.

Partial resection of presurgical fMRI activation is associated with a postsurgical loss of language function after frontal lobe epilepsy surgery

ABSTRACTWe describe five patients with frontal lobe epilepsy who underwent electrocortical stimulation (ES) for language localization and language functional magnetic resonance imaging (fMRI) prior to epilepsy surgery. Six months after surgery, three patients suffered from a drop of verbal fluency. In all of them, frontal areas with presurgical language fMRI activity were resected. Our results suggest that resection in regions of areas with presurgical fMRI activation is not without risk for a postsurgical loss of function, even when ES results were negative for language function in these areas. Using fMRI activations might be specifically helpful to plan the resection when ES delivered inconclusive results.

Few Cognitive Problems Found from Frontal Lobe Epilepsy Surgery, but Also Few Predictors of Trouble

Few Cognitive Problems Found from Frontal Lobe Epilepsy Surgery, but Also Few Predictors of Trouble

Tailored unilobar and multilobar resections for orbitofrontal-plus epilepsy.

Surgery for frontal lobe epilepsy often has poor results, likely because of incomplete resection of the epileptogenic zone. To present our experience with a series of patients manifesting 2 different anatomo-electro-clinical patterns of refractory orbitofrontal epilepsy, necessitating different surgical approaches for resection in each group. Eleven patients with refractory epilepsy involving the orbitofrontal region were consecutively identified over 3 years in whom stereoelectroencephalography identified the epileptogenic zone. All patients underwent preoperative evaluation, stereoelectroencephalography, and postoperative magnetic resonance imaging. Demographic features, seizure semiology, imaging characteristics, location of the epileptogenic zone, surgical resection site, and pathological diagnosis were analyzed. Surgical outcome was correlated with type of resection. Five patients exhibited orbitofrontal plus frontal epilepsy with the epileptogenic zone consistently residing in the frontal lobe; after surgery, 4 patients were free of disabling seizures (Engel I) and 1 patient improved (Engel II). The remaining 6 patients had multilobar epilepsy with the epileptogenic zone located in the orbitofrontal cortex associated with the temporal polar region (orbitofrontal plus temporal polar epilepsy). After surgery, all 6 patients were free of disabling seizures (Engel I). Pathology confirmed focal cortical dysplasia in all patients. We report no complications or mortalities in this series. Our findings highlight the importance of differentiating between orbitofrontal plus frontal and orbitofrontal plus temporal polar epilepsy in patients afflicted with seizures involving the orbitofrontal cortex. For identified cases of orbitofrontal plus temporal polar epilepsy, a multilobar resection including the temporal pole may lead to improved postoperative outcomes with minimal morbidity or mortality.

Finally, a flood of fascinating facts and findings on final outcomes after frontal lobe epilepsy surgery.

Finally, a flood of fascinating facts and findings on final outcomes after frontal lobe epilepsy surgery.

Epilepsy Surgery Series: A Study of 502 Consecutive Patients from a Developing Country

Purpose. To review the postoperative seizure outcomes of patients that underwent surgery for epilepsy at King Faisal Specialist Hospital & Research Centre (KFSHRC). Methods. A descriptive retrospective study for 502 patients operated on for medically intractable epilepsy between 1998 and 2012. The surgical outcome was measured using the ILAE criteria. Results. The epilepsy surgery outcome for temporal lobe epilepsy surgery (ILAE classes 1, 2, and 3) at 12, 36, and 60 months is 79.6%, 74.2%, and 67%, respectively. The favorable 12- and 36-month outcomes for frontal lobe epilepsy surgery are 62% and 52%, respectively. For both parietal and occipital epilepsy lobe surgeries the 12- and 36-month outcomes are 67%. For multilobar epilepsy surgery, the 12- and 36-month outcomes are 65% and 50%, respectively. The 12- and 36-month outcomes for functional hemispherectomy epilepsy surgery are 64.2% and 63%, respectively. According to histopathology diagnosis, mesiotemporal sclerosis (MTS) and benign CNS tumors had the best favorable outcome after surgery at 1 year (77.27% and 84.3%, resp.,) and 3 years (76% and 75%, resp.,). The least favorable seizure-free outcome after 3 years occurred in cases with dual pathology (66.6%). Thirty-four epilepsy patients with normal magnetic resonance imaging (MRI) brain scans were surgically treated. The first- and third-year epilepsy surgery outcome of 17 temporal lobe surgeries were (53%) and (47%) seizure-free, respectively. The first- and third-year epilepsy surgery outcomes of 15 extratemporal epilepsy surgeries were (47%) and (33%) seizure-free. Conclusion. The best outcomes are achieved with temporal epilepsy surgery, mesial temporal sclerosis, and benign CNS tumor. The worst outcomes are from multilobar surgery, dual pathology, and normal MRI.

Does Early Surgery for Frontal Lobe Epilepsy Improve Seizure-Free Outcomes?

In this study, the authors took advantage of their large group of 76 adults and 82 children undergoing frontal lobe epilepsy surgery to determine which

Predictors of decline in verbal fluency after frontal lobe epilepsy surgery

Few studies have focused on language changes following frontal lobe epilepsy (FLE) surgery. The aim of the current study is to quantify the role of resection location and size in verbal fluency decline after FLE surgery and to examine its predictors. A retrospective chart review identified 36 adult patients who underwent FLE surgery. Verbal fluency was assessed using the Controlled Oral Word Association Test (COWAT). Nine (25%) of the patients had significant decline. Binary logistic regression incorporating side of resection and preoperative COWAT score significantly predicted decline and accounted for 25% of the variance. A trend was also noted for decliners to have higher postoperative seizure recurrence (p=0.067). There was no effect of size of resection. Patients undergoing FLE surgery are at risk of verbal fluency decline, especially if they have a high presurgical verbal fluency score, undergo a frontal lobe resection in the language dominant hemisphere, and have poor seizure outcome.

Improved outcomes with earlier surgery for intractable frontal lobe epilepsy

To explore the prognostic implications of epilepsy duration and age at surgery for seizure outcomes after frontal lobe epilepsy (FLE) surgery. We reviewed 158 patients who underwent FLE surgery from 1995 to 2010. The primary outcome was seizure freedom at last follow-up (Engel class IA). Analyses employed Cox proportional and multiphase hazard modeling. The mean age at surgery was 20.4 years, and mean epilepsy duration was 12.0 years. The estimated chance of seizure freedom was 66% (95% confidence interval [CI] = 62-68) at 1 postoperative year, 52% (95% CI = 48-56) at 2 years, and 44% (95% CI = 39-49) at 5 years and beyond. Seventy-five percent of recurrences occurred within 6 postoperative months. Both younger age at surgery (<18 years) and shorter epilepsy duration (<5 years) correlated with better seizure outcomes on univariate analysis, but only epilepsy duration remained statistically significant after multivariate modeling. Independent poor prognostic indicators included left-sided resections and acute postoperative seizures (APOSs; whole model log-rank test p < 0.0001). APOSs were particularly predictive of early epilepsy recurrence, starting within 6 postoperative months (adjusted risk ratio [RR] = 4.42, p < 0.0001), whereas long epilepsy duration correlated with late recurrences (RR = 6.25, p < 0.0001). Worse outcomes were seen with longer epilepsy duration for duration cutoffs of 2, 5, and 10 years independently for adults and children, although statistical significance was only achieved in children (66% seizure free at 5 postoperative years if operated on within 5 years of epilepsy onset vs 31% if later; p = 0.01). Early resection may improve seizure outcomes of FLE surgery, particularly in children.

Outcome of frontal lobe epilepsy surgery

There is still controversy in deciding which patients with frontal lobe epilepsy (FLE) should undergo resective surgery, even though it is a well-established therapy. The aim of this study is to define multiple outcome measures and determine whether there are certain subpopulations of preferred surgical candidates that have a more favorable seizure prognosis. Fifty-eight patients underwent resective FLE surgery with a mean follow-up period of 79.3 months (range 12-208 months). Patient demographics, clinical seizure characteristics, seizure-onset zone within the frontal lobes, and diagnostic tests were tabulated. Engel class, International League Against Epilepsy (ILAE) class, postoperative seizure patterns, time to first recurrent seizure, and seizures and employment during the last year of follow-up were used as outcome measures. Neuropsychological performance and Beck Depression Inventory (BDI) scores were used to define neuropsychological outcome and examined as predictors of seizure outcome. Thirty-three (57%) patients with resective surgery had an Engel class I outcome and 29 (50%) had an ILAE class I outcome. Mean time to first seizure after surgery was 33.3 months (range 0-208). Only 14 patients (24%) were completely seizure-free without auras (Engel IA) throughout the entire follow-up period. The most common pattern of seizure recurrence was mixed, with prolonged periods of seizure freedom intermixed with recurrences. In addition, 32% of patients made gains in employment and 52% were able to reduce use of antiepileptic drugs (AEDs), although only 9% discontinued AEDs. No significant association was found between class I or class IA outcome and the presence of a focal magnetic resonance imaging (MRI) abnormality, any specific localization of seizure focus within the frontal lobe, or neuropsychological change. Findings indicate that that long-term outcome is generally favorable in FLE resective surgery, and support the need for considering multiple outcome measures to more fully characterize clinically relevant postsurgical changes. Outcome can be favorable even in MRI-negative patients.