The prevalence of refractory epilepsy is about 5 to 8 cases per persons 6 , 7. According to Iranian Epilepsy Association, of the registered epileptic patients by , were drug-resistant 8. To achieve better control of seizures which are not controlled by AEDs, other therapeutic options such as ketogenic regimens, deep brain stimulation, responsive neurostimulation, and epilepsy surgery were introduced. Nonetheless, about one-third to half of the patients are eligible for epilepsy surgery as the main therapeutic approach for chronic, drug-resistant epilepsy 9 , 10 , 11 , 12 , 13 , Surgical treatment of refractory epilepsy is a well established therapeutic approach which has been successful in controlling seizure episodes.
However one must bear in mind when evaluating a treatment such as epilepsy surgery, that QoL is also affected by factors such as regional variations in access to rehabilitation 15 , treatment choices 16 , comorbid conditions and social supports 17 worldwide. To our knowledge, there is no previous study about QoL as a tool for evaluating the advantages of epilepsy surgery over other treatment options available in Iran.
The neurosurgery department of Loghman Hakim hospital is one of the most important centers in Iran in which epilepsy surgery is commonly performed. This study aims to assess the results of epilepsy surgery and its impact on health-related quality of life in different aspects such as the mental, physical, living environment and social domains in patients with epilepsy. Since literature lacked a study comparing QoL in patients treated for epilepsy either by surgery or medication in Iran, the present study was designed to perform this QoL comparison between medically controlled patients and healthy controls.
Among the patients undergoing epilepsy surgery in Loghman Hakim hospital between the years of to , 60 were included in the study. In 13 patients Among 22 patients suffering from GS, 10 Among 27 patients undergoing temporal mesial lobectomy, 16 Among 13 patients who underwent neocortical resection, 5 Irrespective of the seizure and surgery type, 31 patients The complications caused by epilepsy surgery could be categorized into two groups including neurological and non-neurological complications.
Neurological complications were classified as two minor and major groups. The rate of major complication which was also 1. We decided to report only the result of the second time for statistical analysis of the study. The average QoL score in the healthy group was The mean score was obtained from questionnaire completed by all the study population indicating that epilepsy surgery could enhance the QoL of patients, as the operated patients had a much better QoL than those with epilepsy receiving AEDs only.
Assessment and comparison of life quality in all three included groups. As described previously, in world health organization WHO quality of life questionnaire, the different domains of QoL are separately evaluated in addition to general assessment of the level of overall QoL.
The result of each domain assessment is separately presented in Fig. In questions 1 and 2, all three groups were asked about their satisfaction with life and their own health condition. In the healthy group, the mean score of the first question was The average score of the second question was Thus, it could be concluded that the operated patients would have a higher level of QoL compared to those taking AEDs Fig. The average score of satisfaction with the physical condition was Therefore, it is highly possible that the operated patients have a better QoL related to this domain compared to that of patients receiving AEDs Fig.
The mean score of satisfaction with the mental condition was In the healthy group, the mean score of satisfaction with the social condition was The last domain of world health organization WHO quality of life questionnaire is the life environment assessment. The average score of this domain of QoL in the healthy group was Thus, epilepsy surgery could bring the patients great satisfaction with this domain of QoL Fig.
To compare the QoL scores of the operated patients with their own baseline scores, a paired sample t-test was conducted.
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- Epilepsy Surgery.
- Frontal lobe epilepsy?
About 40 million people with epilepsy live in developing countries 18 , where the condition remains largely untreated because of limited resources, lack of essential drugs, and psychosocial consequences of stigma about their condition Based on the literature, it is clear that good outcomes for epilepsy surgery can be achieved in low- and middle-income countries However, outcomes vary based on epilepsy type, expertise, and equipment employed during surgery.
Iran is a middle-income country in Western Asia with over 81 million inhabitants. Sayehmiri et al. Reports demonstrate that the poor awareness of epilepsy surgery among physicians, the lack of health-care infrastructure 21 and neurosurgeons 22 are the main reasons that make epilepsy surgery only a theoretical option in Iran. In this study, we have reported the results of different epilepsy surgery methods and their impact on QoL through prospective, controlled follow-up in Iranian patients with epilepsy. The study included the patients that underwent temporal mesial lobectomy, lesionectomy, or anterior callosotomy in Loghman-Hakim hospital between and Comparison of the efficacy of different therapeutic approaches to each other, particularly to those introduced recently such as neuromodulation and selective ablation using laser-thermal technology is beyond the scope of this study; however, these advanced methods are being recently employed in our department which could be the basis of larger studies in the future.
The results of the study showed that Furthermore, postoperative electroencephalograms EEGs indicated improvement in every forty-two patients with therapeutic intention. In some studies, it has been suggested that generalized seizure can be a predictive factor for poor outcome of surgery 24 , 25 , while some other studies reported that surgical outcome would not be affected by generalized seizures 26 , 27 , Seizure types and surgical outcome were not related in some other reports 29 , The most current surgical procedure in our study was mesial temporal lobectomy performed in 27 patients leading to complete freedom of disabling seizures in the majority of them.
In addition, anterior corpus callosotomy was the second common surgical procedure resulting in seizure freedom in half of the patients undergoing this type of surgery. This is in agreement with some other studies in which it has been suggested that the surgery site is not associated with the surgical outcome 31 , 32 , Mere reduction or control of seizure episodes cannot determine the success of a therapeutic approach for establishing a new treatment program in a middle-income country. What patients and clinicians expect from treatment should also be brought into account when evaluating the success of therapeutic approaches.
Surgical Treatment of Neurocysticercosis-Related Epilepsy
Therefore, in order to evaluate treatment outcomes, different aspects must be considered comprehensively. QoL is a useful method to assess this. QoL is most likely to improve by seizure reduction, though unexpected effects of surgery may contribute to poor QoL despite the reduction in seizure frequency 34 , 35 , 36 , 37 , 38 , There are some recent studies on the positive impact of epilepsy surgery on QoL, assessed with various questionnaires 40 , In this study; we used a generic QoL instrument in our study because when the study started, it was the only test that was validated in Persian.
Previous researches have shown that disease-specific instruments are more sensitive to change than generic instruments. Therefore, we expect that the use of a disease-specific QoL survey will increase detecting change over time among the domains. Employing such evaluating tools can help determine success rates of treatment especially in a developing country.
Epilepsy Surgery: Current Status and Ongoing Challenges
In the present study, the QoL of the healthy group members was better than that of the operated patients whose QoL was however higher compared to that of non-operated patients with epilepsy taking AEDs. The difference in QoL between the operated and non-operated patients could be due to lower seizure frequency in the operated patients as mentioned in another study Furthermore, reduction in the number and dosage of AEDs taken by the operated patients following surgery and also reducing the constraints causing the patients with epilepsy not to be able to participate in different sports and social activities by performing surgery would be the other causes of a higher QoL in the operated patients.
Nevertheless, in some studies, it has been mentioned that the QoL of the patients with epilepsy would be improved only with the complete achievement of seizure freedom 43 , The small group of included patients and the short term follow up in these studies necessitate more prospective studies to determine the probable causes. The difference in QoL between the healthy group and the operated patients was significant in all domains of QoL, except in social and life environment domains, while the non-operated patients had lower scores in all domains of QoL compared to the operated patients.
Therefore, it could be concluded that the operated patients would have similar compatibility with the life environment and the same ability as the healthy group to establish personal and social contact following surgery since both groups were the same in social and life environment domains of QoL. Moreover, epilepsy surgery would make patients with drug-resistant epilepsy to have a higher QoL as reported by Shi-Yong Liu et al. Most review studies on epilepsy surgery outcomes in developing countries point to its efficiency in these nations. Asadi-Pooya et al.
Another interesting finding of this study, that is the first report in Iran, is the increased QoL of the patients in all domains of life quality assessment after the surgery which was obtained from a comparison of given scores of the patients, pre- and postoperation. This finding strongly suggests that epilepsy surgery, if properly chosen and performed, can leave the patient with significantly more quality of life in Iran as a developing country.
Reviewing the complications, no death has been reported peri-operatively or from complications of surgery. The most common non-neurological complications include infection of the incision site, surgery site hematoma, pneumonia and brain edema necessitating re-craniotomy. Medical complications were reported in 6. This difference in the incidence of medical complications can be due to limited access to high-quality postoperative care and high prevalence of postsurgical infection in a developing country 49 , Sindou et al.
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No mortality was reported in this study. In another study in Canada 52 , operated patients were included in which no major surgical complication was reported and the rate of incision site infection and hematoma was reported as 1 and 0. The rate of neurological complication was 3. Hemiparesis was the most common one and no mortality was reported. The low rate of mortality in the recent studies was obtained after employing microneurosurgery.
According to Hader et al. The majority of minor neurological complications are associated with temporal lobe resection, as the effects tend to resolve over time completely In our study, the rate of transient postoperative complications was higher than that of the studies mentioned above whereas the permanent complications rate was in line with other studies. This difference in the incidence of transient complications can be due to surgical approach because temporal lobe resection was the most commonly used surgical method in our study. Besides, low socioeconomic level and difficult access to large cities neurosurgical centers 53 make patients more likely to experience severe symptoms before the first visit.
Excessive attention to traditional therapies and lack of educational books and resources about alternative therapies conduce patients not to accept epilepsy surgery therapy at the first step and not to take into account the postoperative rehabilitation recommendations. Insurance coverage limitation for some diagnostic tests is another reason for this shortcoming On the contrary, very few surgeons experienced in epilepsy surgery are trained abroad and these operations only take place in major cities.
This workload degrades proper attention to postoperative care. The limitations of this study should be noted. The sample size is small so a type II error may have been committed. A larger group of patients in every type of surgery is required to adequately evaluate the therapeutic effects.
Due to the importance of the surgical outcome, a Wada test was required to look at language and memory function on each side of the brain, which was not possible for this study. The results of our study revealed that the majority of patients with epilepsy in Iran could experience seizure freedom or dramatic reduction in disabling seizures following epilepsy surgery irrespective of the type of surgery and the type of seizure. We found that patients undergoing epilepsy surgery had a much greater QoL compared to non-operated patients taking only AEDs.
Moreover, surgical treatment appeared to be associated with a low rate of morbidity and no mortality, indicating the high efficacy of the surgical procedure in the treatment of patients with epilepsy. In this study, we prospectively recorded the data of all patients who underwent epilepsy surgery in Loghman Hakim hospital from to Loghman Hakim hospital is a tertiary referral center and one of the most equipped neurosurgical centers in Iran.
Exclusion criteria included previous epilepsy surgery, neurostimulation, syndromic epilepsy, and neurometabolic disorders. The study design was approved by the ethics committee of Shahid Beheshti University of Medical Sciences.
Of the epileptic patients referring to Loghman- Hakim Hospital Neurology Clinic whose disease was controlled on AEDs therapy, 60 patients who matched operated group for age, gender and education and were willing to participate in the study were chosen as the group of patients controlled on AEDs. In order to obtain a healthy control group, flyers were disseminated throughout the hospital and 60 of the volunteers who matched the previous two groups of our study for age, gender and education were selected.
Participants of the healthy control group could not be family members of epileptic patients. Also, neither these participants nor their family members had a chronic disease, since it could negatively affect their QoL. Patients were referred for surgery by an experienced team consisting of a neurosurgeon, an epileptologist and an anesthesiologist.
After extensive preoperative evaluation, including a detailed history of the patients and physical examination, video-electroencephalography, brain magnetic resonance imaging MRI was performed to exclude any secondary causes as well as confirming the diagnosis. Patients were also assessed for intelligence quotient IQ and neuropsychiatric conditions.
Cases of hippocampal sclerosis, hippocampus atrophy or any other pathological changes on MRI related to epileptogenic foci were considered as the best candidates for epilepsy surgery. In patients that MRI showed none of the pathological changes mentioned above or demonstrated extra-temporal impaired regions, epileptogenic foci were determined by means of EEGs. In some patients, molecular imaging methods were also employed if needed. For example, patients in whom MRI failed to reveal pathological changes, the presence of focal showing regions evidenced by EEG along with focal hypo-metabolic foci on Single-photon emission computed tomography SPECT was considered as possible candidates for surgery.
In this study, epilepsy surgery is categorized into therapeutic or palliative surgery. For lesions of the inner surface of the temporal lobe, temporal mesial lobectomy was performed including microsurgical removal of hippocampal and amygdala structures. For lesions of the neocortex, complete lesionectomy was performed, if the lesion was located somewhere other than eloquent cortex and its removal caused no severe disability to the patients.
Adult Epilepsy Surgical Options | Neurosurgery | University of Pittsburgh
In patients with the history of drop attack without any lesion related to the epileptogenic foci, anterior callosotomy was performed. In this surgical procedure, the patient was positioned supine and an S-shaped incision was made on the right coronal suture region. They can also be used for extraoperative cortical stimulation to map out specific areas of cortical function. Unfortunately, subdural electrodes cannot record directly from the deep cerebral structures i. Intracerebral depth electrodes can be placed stereotactically into deep cerebral structures with the aid of CT, MR and angiography.
Most centers employ flexible electrodes with multiple contact points that are placed through small holes in the skull and secured with some form of cranial fixation. Figure 4 Electrodes are usually targeted towards the amygdala, hippocampus, orbital-frontal and cingulate regions and may be inserted via a lateral or vertex approach.
Using a lateral approach, stereotactic cerebral angiography must be utilized to avoid major blood vessels during placement of the depth electrodes. Depth electrodes may be used in combination with scalp or subdural electrodes for more extensive coverage.
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