BACKGROUND: Surgery is an important therapeutic option in patients with medically refractory epilepsy. The combination of an extratemporal epileptic focus and nonlesional magnetic resonance imaging (MRI) was often believed to portend a poor outcome.
OBJECTIVE: To investigate the outcome and analyze potential prognostic predictors in patients without lesions on MRI who underwent extratemporal resections.
METHODS: Clinical, presurgical evaluation, invasive monitoring, and postoperative data of patients with high-resolution MRI that was initially reported as nonlesional were reviewed. Patients were reclassified as MRI-positive if an MRI abnormality related to the epilepsy was revealed at the multidisciplinary presurgical patient management conference, or as MRI-negative if imaging remained normal or revealed incidental findings.
RESULTS: Sixty patients were identified; 72% were MRI-negative. In the original cohort, the median seizure-free duration was 1.32 years (95% confidence interval [CI], 0.16-2.0); probability of seizure freedom at 2 years was 36% (95% CI, 30%–43%). In the MRI-negative group, the median seizure-free duration was 1.52 years (95% CI, 0.12-5.17); probability of seizure freedom at 2 years was 42% (95% CI, 33%–50%). Complete resection of ictal onset areas and absence of acute postoperative seizures were significantly associated with longer seizure freedom (risk ratio 4.9, P = .004; 95% CI, 1.6-16.7 and 22.1, P < .001; 95% CI, 5.9-94.7, respectively).
CONCLUSION: Among patients with medically refractory MRI nonlesional extratemporal epilepsy, detailed evaluation and subsequent resection leads to seizure freedom in 42% of patients at 2 years.
ABBREVIATIONS: APOS, acute postoperative seizure
CI, confidence interval
FCD, focal cortical dysplasia
PET, positron emission tomography
PMC, patient management conference
VNS, vagal nerve stimulator
*Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore;
‡Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
Correspondence: Lara E. Jehi, MD, Epilepsy Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195. E-mail: firstname.lastname@example.org
Received September 20, 2011
Accepted March 19, 2013