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Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes

  • Clinical Article - Functional
  • Published:
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Abstract

Objective

Cerebral cavernous malformations (CCM) of the temporal lobe often present with seizures. Surgical resection of these lesions can offer durable seizure control. There is, however, no universally accepted methodology for assessing and surgically treating these patients. We propose an algorithm to maximize positive surgical outcomes (seizure control) while minimizing post-surgical neurological deficit.

Methods

A retrospective review of 34 patients who underwent epilepsy surgery for radiographically proven temporal lobe CCM was conducted. Patients underwent a relatively standard work-up for seizure localization. In patients with mesial temporal lobe epilepsy (MTLE), a complete resection of the epileptogenic zone was performed including amygdalo-hippocampectomy in addition to a lesionectomy if not contraindicated by pre-operative work-up. Patients with neocortical epilepsy underwent intraoperative electrocorticography (ECoG)-guided lesionectomy.

Results

Seizure-free rate for mesial and neocortical (anterior, lateral, and basal) location was 90 vs. 83 %, respectively. Complete resection of the lesion, irrespective of location, was statistically significant for seizure control (p = 0.018). There was no difference in seizure control based on disease duration or location (p > 0.05). Patients with mesial temporal CCM who presented with MTLE were presumed to also have mesial temporal sclerosis (MTS), or dual pathology. These patients underwent routine resection of the mesial structures. Interestingly, patients who had MTLE and basal (neocortical) lesions who underwent a mesial resection for suspected MTS were found not to have dual pathology.

Conclusions

Patients with temporal lobe CCM should be offered resection for durable seizure control, prevention of secondary epileptogenic foci, and elimination of hemorrhage risk. The preoperative work-up should follow a team approach. Surgical intervention should include complete lesionectomy in all cases. Intra or extra-operative ECoG for neocortical lesions may be beneficial. Management of mesial temporal CCMs (archicortex) should consider resection of a well-defined epileptogenic zone (including mesial structures) due to high probability of pathologically proven MTS. The use of this treatment algorithm is useful for the education and treatment of these patients.

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Abbreviations

MTLE:

Mesial temporal lobe epilepsy

MTS:

Mesial temporal sclerosis

ECoG:

Electrocorticography

MRI:

Magnetic resonance imaging

CCM:

Cerebral cavernous malformations

EC:

Engel classification

EEG:

Electroencephalography

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Acknowledgments

The authors thank Jason Liounakos, B.S., for his help with data collection, Katie Eichsteadt, MA, for the statistical analysis, and Mark Greenberg, M.D., for his art work.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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Authors and Affiliations

  1. Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA

    Fernando L. Vale, Andrew C. Vivas & Jotham Manwaring

  2. Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA

    Mike R. Schoenberg

  3. Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA

    Selim R. Benbadis

Authors
  1. Fernando L. Vale
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  2. Andrew C. Vivas
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Correspondence to Fernando L. Vale.

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Comments

The authors describe a series of 34 retrospectively analyzed resected cavernomas in the temporal lobe. This short paper gives a nice overview of the problems of cavernomas regarding both epilepsy and risk of bleeding and it has a relevant literature discussion. The authors discuss the problem of a lesion present in or close to the mesial structures. Their strategy has been to resect also the medial structures, and they could verify mesial sclerosis. From my point of view, I have two things in the article where I do not fully agree, or at least would not do the same way as the authors. The first is the Wada test. At my clinic we do not do Wada test anymore, and if we did, we would not do it for memory, only for language, since the proven value of Wada for memory test is low. The second is that I would prefer to spare the mesial structures, since usually cavernomas have quite a nice limit to normal tissue. The exception would of course be if you find extensive changes preoperatively in the mesial structures. However, in this article, the preoperative MRI regarding hippocampus was in some patients normal, even if the pathoanatomical diagnosis showed hippocampal sclerosis. I would advocate for a pure lesionectomy, and in some cases prefer to do a second surgery. However, these strategies vary, and I do recommend reading this well-written article.

Bertil Rydenhag

Göteborg, Sweden

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Vale, F.L., Vivas, A.C., Manwaring, J. et al. Temporal lobe epilepsy and cavernous malformations: surgical strategies and long-term outcomes. Acta Neurochir 157, 1887–1895 (2015). https://doi.org/10.1007/s00701-015-2592-4

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