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Presenter : dr. SteviyaniModerator : dr. Iskandar Nasution Sp.S FINS

OUTCOME OF FRONTAL LOBE

EPILEPSY SURGERY

3rd Journal Reading

Wednesday, 19 November 2014

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INTROD!TION

" #$ile$sy surgery is a %ell&es'ablis(ed '(era$y )or

)ron'al lobe e$ile$sy *+#-" .u//ess ra'es vary be'%een 20 and 0, %i'( mos'

s'udies re$or'ing a )avorable seiure ou'/ome o)

#ngel /lass I or /lass I in around 0o) $a'ien's" 5o%ever, ou'/ome measures o) '(ose s'udies are

no' uni)orm and o)'en )o/us on s(or'&'erm ou'/ome

" I' is %ell es'ablis(ed '(a' +# surgery is lesssu//ess)ul '(an 'em$oral lobe e$ile$sy surgery %i'(

res$e/' 'o seiure ou'/ome

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" Rese/'ions o) '(e su$$lemen'ary mo'or area *.6- are

'(oug(' 'o (ave a rela'ively more )avorable ou'/ome

'(an rese/'ions in o'(er regions %i'(in '(e )ron'al lobes

" 7arious surgi/al /en'ers (ave di))eren' surgi/ala$$roa/(es and indi/a'ion /ri'eria )or +# surgery

" $o'en'ial limi'a'ion o) many s'udies inves'iga'ing

ou'/ome )ollo%ing rese/'ion )or +# is '(e relian/e on

one s$e/i)i/ ou'/ome measure, %(i/( is /ommonly)reedom )rom disabling seiures or #ngel ou'/ome

/lassi)i/a'ion

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" T(e $resen' s'udy evalua'ed mul'i$le ou'/ome

measures )ollo%ing surgery )or +# in/luding

several seiure ou'/ome measures, em$loymen',and redu/'ions in #D

" +ur'(ermore, neuro$sy/(ologi/al $er)orman/e and

de$ression %ere also e8amined, as '(ey (ave

been re$or'ed 'o a))e/' %ell&being moresigni)i/an'ly '(an seiure ou'/ome

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6#T5OD.

" a'ien's %i'( a diagnosis o) in'ra/'able +# and

subse:uen' in'ra/ranial ##; s'udy and

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" +ollo%&u$ da'a %ere ob'ained via re$ea'ed /lini/ visi's

" os'o$era'ive neuro$sy/(ologi/al 'es'ing %as$er)ormed a minimum o) mon'(s a)'er surgery" I/'al .#!T, in'eri/'al s/al$ ##;, i/'al s/al$ ##;,

and #T resul's %ere /lassi)ied as ei'(er /on/ordan'

or no' /on/ordan' %i'( '(e area rese/'ed

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.eiure ou'/ome

".eiure&rela'ed ou'/ome measures %ere 'abula'ed based

on yearly )ollo%&u$ da'a"T(is in/luded #ngel /lass and sub/lasses, '(e In'erna'ional

eague gains' #$ile$sy /lassi)i/a'ion sys'em, 'ime 'o '(e

$a'ien'?s )irs' $os'o$era'ive seiure, and %(e'(er '(e $a'ien'

%as )ree o) disabling seiures during '(e las' year o) )ollo%&

u$"T(e 'ime 'o '(e )irs' $os'o$era'ive seiure %as /(ar'ed )or

use in @a$lan&6eier analysis"ll ou'/ome da'a %ere /olle/'ed by $ersonnel *.- no'

involved in /lini/al /are o) '(e $a'ien's

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#m$loymen' ou'/ome"os'o$era'ive em$loymen' %as /om$ared 'o $reo$era'ive

em$loymen'=

"ar'&'ime %or>, )ull&'ime %or>, )ull&'ime s'uden'

#D Ou'/ome"os'surgi/al redu/'ion in number o) an'ie$ile$'i/ drugs

*#Ds- or redu/'ion in #D dosage %as also /onsidered as

an ou'/ome measure"T(e number and dosage o) #Ds a' '(e las' )ollo%&u$ %as

/om$ared 'o '(e number and dosage o) #Ds 'a>en

immedia'ely be)ore surgery

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" ll 'es's, (o%ever, o//urred

%i'(in 2 years be)ore or a)'er

surgery" In'elle/'ual )un/'ioning

WI." 6emory!7T To'al Trials

1A and ong&Delay +ree

Re/all, B '(e ogi/al 6emory

sub'es' )rom '(e W6." anguage Cos'on

Naming Tes'" $(onemi/ )luen/y'(e

!on'rolled Oral Word

sso/ia'ion Tes' or

" '(e 7erbal +luen/y sub'es'

Delis&@a$lan #8e/u'ive +un/'ion

.ys'em=

" ro/essing s$eedTrail6a>ing Tes' ar' or

" !ondi'ion 2D@#+. Trail

6a>ing" #8e/u'ive )un/'ionsTrail

6a>ing Tes' C or /ondi'ion 4

D@#+. Trail 6a>ing" De$ressionCe/> De$ression

Inven'ory

Neuro$sy/(ologi/al 'es'ing

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.TTI.TI! N.I.

" nivaria'e and mul'ivaria'e s'a'is'i/al analyses %ere u'ilied 'o

'es' )or $redi/'ors o) ou'/ome

" +is(er?s e8a/' 'es' %(en small grou$ sie $re/luded '(e use o)/(i&s:uare analysis, and $aired '&'es's

" @rus>al&Wallis 'es's %ere also u'ilied )or analysis o)

de$ression s/ores" 6ul'i$le logis'i/ regression %as '(en u'ilied 'o 'es' )or

signi)i/an' $redi/'ors o) seiure, em$loymen', andneuro$sy/(ologi/al ou'/ome

" @a$lan&6eier analysis %as used 'o /al/ula'e '(e $robabili'y o)

remaining #ngel /lass I '(roug(ou' '(e )ollo%&u$

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R#.T.

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RO;NO.TI!

+!TOR.

" T(e $resen/e o) a lesion on 6RI did no' /orrela'e %i'( #ngel

ou'/ome, sugges'ing '(a' $a'ien's %(o %ere 6RI nega'ive

%ere no' less li>ely 'o be seiure&)ree or 'o (ave a /lass I

ou'/ome '(an 6RI&$osi'ive $a'ien's *$ E 0=2FG$ E 0=HF2-" T(ere %as no' a s'a'is'i/ally signi)i/an' di))eren/e be'%een

$a'ien's %i'( normal $a'(ology versus abnormal $a'(ology in

'erms o) a/(ieving ei'(er seiure )reedom *#ngel IG $ E

0=13G Table .1- or a /lass I #ngel ou'/ome *$ E 0=199G Table

.1-" 7ariables rela'ed 'o in'ra/ranial moni'oring su/( as '(e 'y$e o)

im$lan' and number o) ele/'rodes did no' /orrela'e %i'(

seiure ou'/ome

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" In'eri/'al ##; )indings %ere no' signi)i/an'ly

asso/ia'ed %i'( #ngel /lass ou'/ome"

I) '(e i/'al s/al$ ##; resul's %ere /on/ordan' %i'('(e la'eralia'ion o) '(e seiure )o/us, '(e $a'ien's

%ere more li>ely '(an o'(ers 'o (ave a /lass I

ou'/ome *$ E 0=02HG n E 3-" T(e only ris> )a/'or 'o /orrela'e %i'( ou'/ome %as

(ead 'rauma *$ E 0=044-, and $a'ien's %i'( '(is ris>)a/'or %ere less li>ely 'o (ave a /lass I ou'/ome

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.#IR# TT#RN.

T(e mos' /ommon $os'o$era'ive seiure $a''ern

%as )ree o) disabling seiures *)ound in 33 o)

$a'ien's-

#6O6#NTOT!O6#

os'o$era'ive em$loymen' %as asso/ia'ed %i'( a

/lass Iou'/ome *$ E 0=01-= T(ere)ore, $a'ien's %(odid no' (ave /lass I ou'/omes %ere more li>ely 'o

no' be em$loyed )ollo%ing surgery=

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#D !5N;#.

.i8'een $a'ien's *2- 'oo> a redu/ed number o) #Ds

a' las' )ollo%&u$, %(ereas 9 *1H- 'oo> an in/reased

number o) #Ds= +i)'een $a'ien's *2H- remained on

iden'i/al medi/a'ions as $reo$era'ively, %i'( eig(' *14-

on redu/ed doses o) '(ose same #Ds

N#RO.!5OO;I!

OT!O6#

T(ere %as no signi)i/an' rela'ions(i$ be'%een $reo$era'ive

or $os'o$era'ive de$ression s/ore and seiure&onse' one, i)

e8amined inde$enden'ly=

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7;. N#R7#

.TI6TION

#ig(' *14- $a'ien's under%en' vagus nerve s'imula'ion

*7N.- a)'er rese/'ive surgery= 7N. %as $la/ed on average

4 mon'(s a)'er '(e rese/'ive surgery

!O6I!TION.

T(ree rese/'ive $a'ien's *=2- e8$erien/ed/om$li/a'ions and %ere readmi''ed= T%o (ad

/erebros$inal )luid *!.+- lea>s and one (ad an in)e/'ion

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DI.!..ION

" Our observa'ion o) an overall #ngel /lass I ou'/ome

o) F and a /ombined #ngel /lass I and II ou'/ome

o) F3 is /onsis'en' %i'( $revious re$or'ed s'udies

" In our series, $a'ien's %i'( nega'ive 6RI did (ave

ou'/omes e:ually good as $a'ien's %i'( de)ini'e

lesions, %(i/( /on'radi/'s mos' $revious re$or's

T(is may be an e))e/' o) sam$le sie

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" .eiure $a''ern T(ese inves'iga'ors re$or'ed a

running&do%n e))e/' *several $os'o$era'ive

seiures be)ore seiure )reedom- in 11, %(i/( is

similar 'o F in '(is s'udy and o'(ers

" .'andardied :uali'y o) li)e measures %ere no'

universally available, bu' e$ile$sy surgery resul'ed

in some em$loymen' gains and re)le/'s $revious)indings '(a' em$loymen' gains /orrela'e %i'(

be''er seiure ou'/ome

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"Neuro$sy/(ologi/al ou'/ome In '(e $resen'

inves'iga'ion, $reo$era'ive neuro$sy/(ologi/al s/ores

did no' $redi/' seiure ou'/ome, and surgery %as no'

asso/ia'ed %i'( signi)i/an' /(ange in

neuro$sy/(ologi/al )un/'ioning= O'(er inves'iga'ions

(ave yielded in/onsis'en' /(anges, %i'( some

re$or'ing memory im$rovemen' in seiure&)ree $a'ien'sdi))eren/es in '(e s$e/i)i/ )ron'al regions '(a' %ere

rese/'ed

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I6ITTION

" I' is a re'ros$e/'ive revie%= .mall sam$le sies

in subgrou$ analysis may mas> sub'le e))e/'s=" '(e re'ros$e/'ive analysis o) neuro$sy/(ologi/al

ou'/ome %as in(eren'ly limi'ed be/ause no' all

$a'ien's 'oo> '(e same ba''eries and u$da'ed

versions o) /er'ain 'es's %ere released during

'(e re'ros$e/'ive $eriod

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!ON!.ION

" +# surgery in all lo/a'ions %i'(in '(e )ron'al

lobe im$roves seiure ou'/ome, bu'

$sy/(oso/ial ou'/ome and /omorbidi'ies su/(as de$ression need more inves'iga'ion

" #$ile$sy surgery s(ould be o))ered 'o +#

$a'ien's, even i) 6RI is nega'ive

" Overall ou'/ome /an also be )avorable even i)'(e $a'ien' is no' /om$le'ely seiure&)ree

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