Abstracts

Rationale: Cognitive and physical disabilities have previously been considered a contraindication for focal resective surgery and often reflect cerebral dysfunction that is associated with regional, diffuse or multi-focal pathology. Because limited information is available regarding the timing of resective epilepsy surgery in patients with disabilities, we reviewed our experience with respect to outcome and treatment delays.Methods: Two-hundred and fifty-eight resective epilepsy surgeries were performed from 2000 to 2006 at one center by one neurosurgeon (FLV). All cases were retrospectively reviewed for functional cognitive or physical disabilities. Eighteen patients (7.0%) included 10 males with a mean age of 35.3 years underwent resective surgery for localization-related epilepsy (LRE). All had either a functional cognitive or physical deficit in additional to uncontrolled seizures. Mental retardation was associated with a Full Scale IQ of <70 on formal neuropsychological testing. A standardized, non-invasive presurgical evaluation was used in every case. Pre-operative characterization of the disability, seizure frequency, seizure-related injuries (excluding tongue or cheek bites), duration prior to surgery, and number of antiepileptic drug (AED) trials were assessed relative to the surgical procedure and outcome (Engel classification). Results: Temporal lobectomy (9 left) was performed in 17/18 (94%) patients without complication. A lesion was present on high-resolution brain MRI in 10/18 (55.5%) cases. Mesial temporal sclerosis was the most frequent “lesion” despite more widespread abnormalities. Cognitive and physical disabilities were similar in frequency (cognitive= 10/18; physical=8/18). Eight of 18 (44.4%) were seizure free after surgery with a mean follow-up of 2.4 years. Only 1 (5.6%) patient had no improvement (3/18 class 2; 5/18 class 3). The mean delay prior to surgery was 24.8 years. Pre-operative AED treatment demonstrated a mean of 7.6 AED trials/ patient (1 with VNS) at the time of surgical evaluation. Fifteen of the 18 (83.3%) patients reported injuries before surgery was performed, and 4/15 (26.7%) were a serious adverse event (burn, fracture, hospitalization). Conclusions: Our patients with cognitive or physical disabilities experienced substantial treatment delays prior to epilepsy surgery. Multiple AED failures and injuries were present despite a substantial number that became seizure free after surgery. Our results agree with newer reports that full-scale IQ and physical or developmental disabilities do not correlate with poor postoperative seizure control. We suggest that epilepsy surgery should be considered for those with disabilities early in the course of treatment when seizures are refractory to AEDs.