| Part Ⅰ Factors influencing the long-term prognosis of temporal lobe epilepsy patientsPurpose The current study was to explore the risk factors influencing the long-term prognosis of temporal lobe epilepsy(TLE)with drug therapy and surgical treatment.Methods A total of 112 TLE patients were retrospectively recruited in epilepsy diagnosis and treatment center of Brain Hospital Affiliated to Nanjing Medical University from Jan 2006 to Jun 2017 with a follow-up of at least 24 months.All of them were treated with antiepileptic drugs(AEDs)initially.The patients meeting the criteria of drug-resistant TLE were evaluated.Noninvasive examination and evaluation(video EEG,MRI,magnetoencephalogram,pet,etc.)were carried out.When the epileptic focus could not be accurately located it was necessary to implant the subdural electrode to observe the seizure of the intracranial electrode and comfirm the beginning.Then the patients were treated with temporal lobectomy.All patients were followed up for at least 24 months after treatment.If there was no seizure for at least 24 months,it was defined as no seizure;if there was no seizure for less than 24 months,there was still seizure.AEDs treatment of TLE,at least 24 months in the observation period epilepsy without seizure,that is defined as "benign temporal lobe epilepsy".AEDs treatment for 3 years without seizure or surgery for 1 year without seizure,after normal EEG,it is suggested that the patients could AEDs withdrawal.A multiple logistic regression model was used to evaluate the independent predictors for the outcome.Results The median follow-up period was 5 years(2-13years).At the end of the follow-up,26 patients achieved no seizure after AEDs treatment,including 22 cases of monotherapy,4 cases of duotherapy(1 case of drug-resistant epilepsy after continuous drug treatment),and AEDs withdrawal in 6 patients.Eventually,23.2% TLE patients(26/112)achieved seizure freedom solely upon AEDs and the rest of 76.8%(86/112)were diagnosed as drug-resistant epilepsy(DRE).Finally,45 DRE patients were received surgical treatment and 77.8% of them(35/45)achieved seizure freedom with an successful AEDs withdrawal in 11 patients.The proportion of the seizure-free patients after temporal lobectomy is higher than that of the continuing-AED patients(77.8% vs 23.2%,P<0.001).The well-responsiveness of early monotherapy was an independent predictor for good therapeutic effect in all TLE patients(OR: 0.16;95% CI: 0.04-0.66;P=0.007).The predictors of a good prognosis in DRE patients after surgery were unilateral origin of discharges in EEG(OR=0.20,95%CI=0.06-0.74,P=0.016),without-secondary GTCS(OR=0.08,95%CI=0.01-0.67,P=0.002)and not using subdural electrode implantation(OR=15.4,95%CI=1.36-174.38,P=0.027)by a multivariate logistic regression analysis.Conclusion 22.3% TEL was benign temporal lobe epilepsy.The well-responsiveness of early monotherapy with AEDs is an independent protective factor for the favorable prognosis of TLE.Unilateral origin of discharges in EEG,without-secondary GTCS and not using subdural electrode implantation are independently favorable prognosis factors for TLE surgery.Part Ⅱ Long term prognosis and its influencing factors of surgical treatment in patients with focal epilepsyPurpose The current study was to explore the risk factors influencing the long-term prognosis of focal epilepsy with surgical treatment.Methods A total of 145 focal epilepsy patients were retrospectively recruited in epilepsy diagnosis and treatment center of Brain Hospital Affiliated to Nanjing Medical University from Jan 2006 to Jun 2017,including 59 patients of drug resistant local epilepsy and 86 patients of lesion related epilepsy.The diagnosis of focal DRE is consistent with the correct use of at least two AEDs that are effective for the type of seizure for more than two years,and the seizure is still at least once a month;the localization of epileptogenic focus was determined after preoperative evaluation;the diagnosis of lesion-related epilepsy is consistent with the application of neuroimaging technology and electrophysiological monitoring technology,which can identify the "responsible lesions" that cause epilepsy.All patients were followed up for at least 12 monthsand the outcome was evaluated by Engel class.A multiple logistic regression model was used to evaluate the independent predictors for the outcome.Results The median follow-up period was 5 years(2-13years).Eventually,54.5% patients(79/145)achieved seizure free at least 12 months,and 67.3% of temporal lobe epilepsy had seizure freedom after surgery,48.8% of frontal lobe epilepsy respectively(67.3% vs 48.8%,p=0.076).60.4% of the patients with positive MRI achieved seizure free after surgery,45.8% of the patients with negative MRI respectively(60.4% vs 45.8%,p=0.081).The proportion of seizure-free of brain MRI positive temporal lobe epilepsy and brain MRI negative extratemporal lobe epilepsy were 69.4% and 37.5% respectively.94 patients(64.8%)had positive pathological results,and 58/94(61.7%)achieved seizure free,including 75% of low-grade tumors,69% of vascular related lesions,68% of hippocampal sclerosis,and 57% of FCD.The short duration of disease,not using subdural electrode implantation,unilateral origin of discharges in EEG,positive postoperative pathological and brain MRI positively are related to the good prognosis of focal epilepsy surgery.The predictors of a good prognosis in focal patients after surgery were unilateral origin of discharges in EEG(OR=3.65,95%CI=1.03-12.97,P=0.046)and positive MRI(OR=0.17,95%CI=0.06-0.47,P=0.001)by a multivariate logistic regression analysis.Conclusion The prognosis of the focal epilepsy surgery is satisfactory.The proportion of temporal lobe epilepsy is the largest and the prognosis is the best in the focal epilepsy surgery.The surgical effect of brain MRI with focal positive lesions is better than that of MRI negative drug-resistant focal epilepsy.Postoperative pathology showed that FCD was the most common in frontal lobe epilepsy and hippocampal sclerosis was the most common in temporal lobe epilepsy.Unilateral origin of discharges in EEG,and brain MRI with focal positive lesions are independently favorable prognosis factors for focal epilepsy surgery.Part Ⅲ Withdrawal of drugs and prognosis in patients with focal epilepsy after surgeryObjective To evaluate the risk factors for seizure recurrence subsequent to antiepileptic drug(AED)withdrawal in patients who underwent surgical treatment for focal epilepsy and were rendered seizure-free.Methods We retrospectively analyzed the postoperative AED profile of 145 consecutive patients in epilepsy diagnosis and treatment center of Brain Hospital Affiliated to Nanjing Medical University for focal epilepsy between 2006 and 2017.To observe the postoperative seizure and the use of AEDs.When the patients reached: 1)Engle class Ⅰa,without any seizure(including the aura)for more than one year;2)the video EEG was normal;3)the patients and / or their families informed consent,the AEDs began to stop.A multiple logistic regression model was used to evaluate the independent predictors for the outcome of AEDs withdrawal.Results In the 145 patients of focal epilepsy,89 patients achieved seizure free at least 12 months after surgery.We attempted AED withdrawal in 44 patients,among them,six patients are still in the drug reduction,30 patients with both complete withdrawal and achieved seizure free for at least one year.The proportion of complete withdrawal was 21%(30/145).The proportion of complete withdrawal was 35%(14 / 40)in patients after temporal lobectomy and 16 / 105(15.2%)in patients after extratemporal lobectomy(P = 0.009).In three(6.8%)patients,seizure relapse developed during AED reduction and in four(9.1%)patients after discontinuation of AEDs.There was no seizure in one patient after discontinuation of AEDs,but the EEG showed epileptiform discharge in the interval of seizure and the medication was resumed.The recurrence rate of withdrawal was 18.4%(7 / 38).The recurrence rate was 18.8% in 8 of 45 patients without drug withdrawal,which was not significantly different from that in 18.4% of patients without drug withdrawal.Among seven patients with seizure relapse related to AED tapering,three of them regained seizure freedom after reinstitution of AED treatment,two of the 8 patients with relapse without drug withdrawal were followed up again.No factors related to recurrence were found.The reason of 37 patients without recurrence not withdrawing AEDs : 16 patients of epileptiform discharge in video EEG,nine patients of multifocality,two patients of worried about recurrence affecting driving and employment;seven patients had early seizure after surgery,3 patients should not be withdrawal because of evaluating the etiology(1 patient after encephalitis,2 patients of tuberous sclerosis)..Conclusion 21% of the patients with focal epilepsy after surgery can achieve long-term seizure free and withdrawal AEDs.The proportion of withdrawal AEDs after temporal lobectomy is higher than extratemporal lobectomy.The withdrawal of AEDs is not a risk factor for the recurrence of focal epilepsy patients after surgery.The recurrence related to withdrawal of AEDs can be well controlled after the reinstitution of AED treatment.The factors of relapse after withdrawal were complex and varied,and no related factors were found in this study. |
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