Temporal lobectomy: long-term seizure outcome, late recurrence and risks for seizure recurrence
Temporal lobectomy: long-term seizure outcome, late recurrence and risks for seizure recurrence
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DOI：
10.1093/brain/awh221
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发表时间：
2004-09-01
期刊：
影响因子：
14.5
通讯作者：
Berkovic, SF
中科院分区：
文献类型：
--
作者：
McIntosh, AM;Kalnins, RM;Berkovic, SF
关于前颞叶切除术后的长期癫痫预后，特别是术后较长时间的癫痫，相关信息很少。这项研究的目的是深入研究肺叶切除术后癫痫复发的纵向结局模式和潜在危险因素，利用长期随访的大样本患者。纳入了1978年至1998年间接受前颞叶切除术的325名患者(平均随访9.6+/-4.2年)。采用生存分析和COX比例风险模型进行多因素回归分析。术后2年癫痫完全缓解的概率为55.3%[95%可信区间为50~61]，5年为47.7%(95%可信区间42~53)，10年为41%(95%可信区间36~48)。与无明显异常的患者相比，术前有离散性异常(即病变和海马区硬化)的患者癫痫发作自由的概率显著增加。后一组的复发模式与切除区域外病变的患者相似。在调整了术前病理因素后，仅有术前继发性全身性发作与复发显著相关[术前偶发性全身性发作，危险比(HR)1.6，95%可信区间1.1~2.3；频繁发作，HR 2.0，95%CI 1.4~2.9与无全身性发作相比]。术前癫痫持续时间、发病年龄和手术年龄对预后无影响。术后2年无癫痫发作的患者术后10年无癫痫发作的概率为74%(95%可信区间66~81)。这种晚期癫痫复发与任何已确定的危险因素无关。具体地说，海马区硬化症患者的风险并不高。令人惊讶的是，术后两年完全停用抗癫痫药物并不增加复发风险(HR 1.03，95%CI 0.5-2.1)。这可能是因为选择停用AED的患者偏向于那些被认为是“低风险”的人。本研究结果提示，无明显异常或弥漫性病理改变，术前继发性全身性癫痫发作是术后复发的危险因素。首次发作自由后晚期复发并不少见；这种现象特有的危险因素尚不清楚。
There is little information available relevant to long-term seizure outcome after anterior temporal lobectomy, particularly at extended postoperative periods. The aim of this study was an in-depth examination of patterns of longitudinal outcome and potential risk factors for seizure recurrence after lobectomy, utilizing a large patient sample with long follow-up. Included were 325 patients who underwent anterior temporal lobectomy between 1978 and 1998 (mean follow-up 9.6+/-4.2 years). Retrospective data were analysed using survival analysis and multivariate regression with Cox proportional hazard models. The probability of complete seizure freedom at 2 years post-surgery was 55.3% [95% confidence interval (CI) 50-61]; at 5 years, 47.7 % (95 % CI 42-53); and at 10 postoperative years it was 41 % (95 % CI 36-48). Patients with discrete abnormalities preoperatively (i.e. lesions and hippocampal sclerosis) had a significantly higher probability of seizure freedom than patients without obvious abnormality. The latter group had a pattern of recurrence similar to that in patients with lesions outside the area of excision. After adjustment for preoperative pathology, only the presence of preoperative secondarily generalized seizures had a significant association with recurrence [occasional preoperative generalized seizures, hazard ratio (HR) 1.6, 95% CI 1.1-2.3; frequent seizures, HR 2.0, 95% CI 1.4-2.9 compared with absence of preoperative generalized seizures]. Duration of preoperative epilepsy, age of seizure onset and age at surgery did not have an effect on outcome. Patients with two seizure-free postoperative years had a 74 % (95 % CI 66-81) probability of seizure freedom by 10 postoperative years. This late seizure recurrence was not associated with any identified risk factors. Specifically, patients with hippocampal sclerosis were not at higher risk. Surprisingly, complete discontinuation of anti-epileptic drugs (AEDs) after two postoperative years was not associated with an increased risk of recurrence (HR 1.03, 95% CI 0.5-2.1). This may be because selection of patients for AED discontinuation is biased towards those individuals perceived as 'low risk'. The results of this study indicate that the lack of an obvious abnormality or the presence of diffuse pathology, and preoperative secondarily generalized seizures are risk factors for recurrence after surgery. Late recurrence after initial seizure freedom is not a rare event; risk factors specific to this phenomenon are as yet unidentified.