Factors predictive of suboptimal seizure control following selective amygdalohippocampectomy

OBJECT: 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. METHODS: 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. CONCLUSIONS: 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.