Objective. - To evaluate the efficiency of resective epilepsy surgery (RES) in patients over 50 years and determine prognostic factors. Results. - Over the 147 patients over 50 years (54.9 +/- 3.8 years [50-69]) coming from 8 specialized French centres for epilepsy surgery, 72.1%, patients were seizure-free and 91.2% had a good outcome 12 months after RES. Seizure freedom was not associated with the age at surgery or duration of epilepsy. In multivariate analysis, seizure freedom was associated with MRI and neuropathological hippocampal sclerosis (HS) (P = 0.009 and P = 0.028 respectively), PET hypometabolism (P = 0.013), temporal epilepsy (P = 0.01). On the contrary, the need for intracranial exploration was associated with a poorer prognosis (P = 0.001). Postoperative number of antiepileptic drugs was significantly lower in the seizure-free group (P = 0.001). Neurological adverse event rate after surgery was 21.1% and 11.7% of patients had neuropsychological adverse effects overall transient. Conclusions. - RES is effective procedure in the elderly. Even safe it remains at higher risk of complication and population should be carefully selected. Nevertheless, age should not be considered as a limiting factor, especially when good prognostic factors are identified. (c) 2021 Elsevier Masson SAS. All rights reserved.

INTRODUCTION:Epilepsy related to brain tumors is often difficult to treat and may impact the quality of life. We performed a review of current recommendations for the prevention of postoperative seizures and optimizing the anti-epileptic treatment. MATERIAL AND METHODS:Based on studies performed since 2000 we conducted the review by (1) analyzing the incidence of tumoral epilepsy and mechanisms of epileptogenicity; (2) describing the current medical and surgical strategy according to oncologic treatments; (3) discussing the management of postoperative seizures; (4) considering the drug withdrawal after oncologic therapy. RESULTS:Epilepsy related to supra-tentorial brain tumors is frequent (40-60%) especially in low-grade gliomas, glioneuronal tumors, fronto-temporal and eloquent cortex locations. Seizures can occur as a presenting symptom or during the course of the tumor, including after surgery and oncological treatments. Maximal safe surgical resection is the more effective therapy, alone or combined with adjuvant therapy (chemotherapy, radiotherapy). Anti-epileptic drugs are not indicated for epilepsy prophylaxis in patients without seizures but only after the first seizure due to high risk of recurrence. As they may generate adverse effects and interfere with oncological treatments, the choice is based on efficacy, tolerability and potential interactions. New anti-epileptic non-enzyme-inducing drugs are recommended in first-line monotherapy in association with adjuvant oncological therapies. Enzyme-inhibiting drugs could have a favorable effect on survival. Late seizures are often related to tumor progression or recurrence. Discontinuation of anti-epileptic drugs could be considered after successful oncological treatment and a stable medical condition. CONCLUSION:These guidelines are helpful for a rational therapy in tumoral epilepsy.

Introduction. - Dysembryoplastic neuroepithelial tumors and gangliogliomas are developmental glioneuronal tumors usually revealed by partial epilepsy. High epileptogenicity, childhood epilepsy onset, drug-resistance, temporal location, and seizure freedom after complete resection are common characteristics of both tumors. We report the specificity of surgical management, functional results and seizure outcome in cases of a tumor location in eloquent areas.Methods. - Among 150 patients (88 males, 3-55 years) operated on for refractory epilepsy due to a glioneuronal tumor (1990-2015), 30 (20%, dysembryoplastic neuroepithelial tumors = 21; gangliogliomas = 9) had a tumor located in an eloquent cortex (sensory-motor, insular or language areas). Surgery was performed after a preoperative work-up, including stereo-electroencephalography in 48 patients (26%) and functional MRI in 100 (67%). MRI-guided lesionectomy was mainly performed in extra-temporal location, whereas an additional corticectomy was performed in a temporal location. Tumor microsurgical resections were guided using neuronavigation and cortical/subcortical electrical stimulations. Multiple stereotactic thermocoagulations were performed in two insular tumors.Results. - New motor/language deficits related to eloquent areas occurred postoperatively in 6/30 patients (20%) without any major permanent disability. Minor sensorimotor (n = 2) and moderate language disturbance (n =1) persisted in three of them. Postoperative seizure-free outcome (mean follow-up > 5 years) was obtained in 81% of the entire series, but significantly decreased to 60% in eloquent areas. Incomplete tumor resection was the main cause of surgical failure. However, unfavorable seizure outcome was also observed despite complete tumor resection. Malignant transformation occurred in one ganglioglioma.Conclusion. - Epilepsy surgery for benign glioneuronal tumors in eloquent areas provides acceptable results regarding the functional risks. Complete tumor resection is crucial for long-term favorable outcome. (C) 2017 Elsevier Masson SAS. All rights reserved.

BACKGROUND:Detailed neuropathological information on the structural brain lesions underlying seizures is valuable for understanding drug-resistant focal epilepsy. METHODS:We report the diagnoses made on the basis of resected brain specimens from 9523 patients who underwent epilepsy surgery for drug-resistant seizures in 36 centers from 12 European countries over 25 years. Histopathological diagnoses were determined through examination of the specimens in local hospitals (41%) or at the German Neuropathology Reference Center for Epilepsy Surgery (59%). RESULTS:The onset of seizures occurred before 18 years of age in 75.9% of patients overall, and 72.5% of the patients underwent surgery as adults. The mean duration of epilepsy before surgical resection was 20.1 years among adults and 5.3 years among children. The temporal lobe was involved in 71.9% of operations. There were 36 histopathological diagnoses in seven major disease categories. The most common categories were hippocampal sclerosis, found in 36.4% of the patients (88.7% of cases were in adults), tumors (mainly ganglioglioma) in 23.6%, and malformations of cortical development in 19.8% (focal cortical dysplasia was the most common type, 52.7% of cases of which were in children). No histopathological diagnosis could be established for 7.7% of the patients. CONCLUSIONS:In patients with drug-resistant focal epilepsy requiring surgery, hippocampal sclerosis was the most common histopathological diagnosis among adults, and focal cortical dysplasia was the most common diagnosis among children. Tumors were the second most common lesion in both groups. (Funded by the European Union and others.).

L’efficacité du traitement chirurgical des épilepsies partielles pharmaco-résistantes (EPPR) sur le contrôle des crises et la qualité de vie est aujourd’hui bien établie. La sélection des candidats repose sur les données cliniques, électrophysiologiques et sur l’imagerie. Celle-ci permet d’identifier les principales étiologies des EPPR curables par la chirurgie : la sclérose hippocampique, responsable de la majorité des épilepsies mésio-temporales, les tumeurs de bas grade d’origine développementale – DNTs et gangliogliomes – les dysplasies corticales focales, les lésions vasculaires et cicatricielles. Un bilan préchirurgical comprenant vidéo-EEG, imagerie anatomique et fonctionnelle, évaluation neuropsychologique et psychiatrique, effectué dans un centre de référence, confirme l’indication et évalue les risques de la chirurgie. Dans certains cas, une implantation d’électrodes intracérébrales pour enregistrement EEG invasif (SEEG) est nécessaire pour identifier la localisation et l’étendue de la région cérébrale responsable des crises et définir la stratégie chirurgicale. Les techniques chirurgicales se sont diversifiées et comprennent les interventions de résection–temporale, extra-temporale, en région fonctionnelle –, les interventions de destruction focale, de déconnexion et de neuromodulation. La prise en charge postopératoire est pluridisciplinaire et comprend la gestion du traitement antiépileptique, le traitement des comorbidités, l’aide à la réinsertion. Les résultats de la chirurgie sur les crises d’épilepsie dépendent avant tout de l’étiologie : la suppression des crises est observée chez 60 % à 80 % des patients dans l’épilepsie mésio-temporale, chez plus de 80 % des patients après résection tumorale et dans plus de 90 % des patients opérés d’une dysplasie corticale focale. La guérison des crises est suivie d’une amélioration significative de la qualité de vie. Le déclin de la mémoire après intervention sur le lobe temporal peut être prédit sur des données cliniques et d’imagerie fonctionnelle. D’autres défis demeurent à relever, dont la réduction des délais d’accès à la chirurgie, l’amélioration des résultats dans l’épilepsie mésio-temporale et l’identification pré- et intra-opératoire des lésions épileptogènes non visibles sur l’imagerie.

Le malformazioni dovute a un'anomalia dello sviluppo corticale (MSC) indicano un ampio spettro di malformazioni cerebrali costituite durante l'embriogenesi. Esse sono responsabili di epilessia e di disturbi neurologici e cognitivi di intensità variabile, in relazione con lo stadio di comparsa dei disturbi e con l'estensione della malformazione. Le classificazioni recenti basate sulla diagnostica per immagini distinguono i disturbi della proliferazione neuronale e gliale (emimegalencefalia, sclerosi tuberosa di Bourneville, displasia corticale focale tipo Taylor [DCFT], tumore disembrioplasico neuroepiteliale [DNT] e ganglioglioma), i disturbi della migrazione neuronale (lissencefalia, eterotopia laminare sottocorticale e nodulare periventricolare o sottocorticale) e i disturbi dell'organizzazione corticale (polimicrogiria, schizencefalia). Le microdisgenesie corrispondono a delle lesioni eterogenee la cui diagnosi può essere stabilita solo con l'esame istologico. La presentazione elettroclinica e radiologica della maggior parte delle MSC è attualmente nota, e alcuni tipi sono riconducibili a un'anomalia genetica ben riconosciuta. Un certo numero di pazienti portatori di MSC (in particolare di DCFT, DNT e gangliogliomi) può trarre beneficio da un trattamento chirurgico. Benché i meccanismi e la storia naturale delle MSC siano tuttora incompletamente conosciuti, i recenti progressi hanno permesso un miglioramento della gestione dei pazienti, della consulenza genetica e delle indicazioni terapeutiche.

BACKGROUND AND PURPOSE: Type 2 FCD is one of the main causes of drug-resistant partial epilepsy. Its detection by MR imaging has greatly improved surgical outcomes, but it often remains overlooked. Our objective was to determine the prevalence of typical MR imaging criteria for type 2 FCD, to provide a precise MR imaging pattern, and to optimize its detection.MATERIALS AND METHODS: We retrospectively reviewed 1.5T MR imaging of 71 consecutive patients with histologically proved type 2 FCD. The protocol included millimetric 3D T1-weighted, 2D coronal and axial T2-weighted, and 2D or 3D FLAIR images. Two experienced neuroradiologists looked for 6 criteria: cortex thickening, cortical and subcortical signal changes, blurring of the GWM interface, the "transmantle" sign, and gyral abnormalities. The frequency of each sign and their combination were assessed. We compared the delay between epilepsy onset and surgery, taking into account the time of type 2 FCD detection by MR imaging.RESULTS: Only 42 patients (59%) had positive MR imaging findings. In this group, a combination of at least 3 criteria was always found. Subcortical signal changes were constant. Three characteristic signs (cortical thickening, GWM blurring, and transmantle sign) were combined in 64% of patients, indicating that MR imaging can be highly suggestive. However, typical features of type 2 FCD were overlooked on initial imaging in 40% of patients, contributing to a delay in referral for surgical consideration (17 versus 11.5 years when initial MR imaging findings were positive).CONCLUSIONS: A combination of 3 major MR imaging signs allows type 2 FCD to be recognized in clinical practice, thereby enabling early identification of candidates for surgery.

Objective: To determine the diagnostic accuracy and prognostic value of 18FDG-PET in a recent series of patients operated for intractable partial epilepsy associated with histologically proven Taylor-type focal cortical dysplasia (TTFCD) and negative MRI. Methods: Of 23 consecutive patients (12 male, 7–38 years old) with negative 1.5-Tesla MRI, 10 exhibited subtle nonspecific abnormalities (e.g., unusual sulcus depth or gyral pattern) and the 13 others had strictly normal MRI. FDG-PET was analyzed both visually after coregistration on MRI and using SPM5 software. Metabolic data were compared with the epileptogenic zone (EZ) determined by stereo-EEG (SEEG) and surgical outcome. Results: Visual PET analysis disclosed a focal or regional hypometabolism in 18 cases (78%) corresponding to a single gyrus (n = 9) or a larger cortical region (n = 9). PET/MRI coregistration detected a partially hypometabolic gyrus in 4 additional cases. SPM5 PET analysis (n = 18) was concordant with visual analysis in 13 cases. Location of PET abnormalities was extratemporal in all cases, involving eloquent cortex in 15 (65%). Correlations between SEEG, PET/MRI, and histologic findings (n = 20) demonstrated that single hypometabolic gyri (n = 11) corresponded to EZ and TTFCD, which was localized at the bottom of the sulcus. Larger hypometabolic areas (n = 9) also included the EZ and the dysplastic cortex but were more extensive. Following limited cortical resection (mean follow-up 4 years), seizure freedom without permanent motor deficit was obtained in 20/23 patients (87%). Conclusions: 18FDG-PET coregistered with MRI is highly sensitive to detect TTFCD and greatly improves diagnosis and surgical prognosis of patients with negative MRI.

Positron emission tomography (PET) using (18)fluorodeoxyglucose ((18)FDG) is currently used in presurgical work-up for drug-resistant partial epilepsies in children as in adults, in addition to MRI. Recent cameras with less than 5 mm spatial resolution allow to obtain thin slices (about 2 mm thickness) in 3D planes. (18)FDG is intravenously injected at the mean dose of 3 MBq/kg of body weight in interictal and resting state, in a quiet, dimly lit environment and careful monitoring for head movements and ictal events. In children, sedation may be necessary. Image acquisition starts 30 min after injection and ended 15 to 20 min later. Semiquantitative analysis is visually assessed in clinical practice using colour scales. PET sensibility is improved by superimposition of metabolic imaging on MRI. Statistical analysis with SPM may be useful but comparison with health subjects database is required. In medial temporal lobe epilepsy associated with hippocampal sclerosis, hypometabolism ipsilateral to the epileptogenic focus is found in 70 to 90% of the cases and is predictive Of Surgical outcome. In other types of temporal and extratemporal epilepsy with negative MRI, focal hypometabolism can be detected, allowing identification of minor gyral abnormalities corresponding to focal cortical dysplasias. In such MRI negative cases, PET findings may improve surgical outcome. (C) 2009 Elsevier Masson SAS. All rights reserved.

Rationale Arterial vasospasm has rarely been reported following temporal lobectomy for intractable epilepsy. Case presentation A 31-year-old patient presented with a global aphasia 2 days after a left dominant anteromesial temporal lobectomy for intractable epilepsy. Magnetic resonance imaging on 5th post-operative day revealed severe narrowing of M1 segment of the left middle cerebral artery (MCA) and Transcranial Doppler (TCD) ultrasonography an increased velocity of the MCA that suggested a severe vasospasm. The patient received continuous intravenous hyperhydratation and nimodipine; aphasia improved within 24 h and resolved completely within 6 weeks, associated with velocity reduction on control TCD. Conclusion Transient vasospasm is a likely underestimated cause of focal deficit following temporomesial resection that deserves appropriate treatment.

Décrire et caractériser les anomalies morphologiques des principaux sillons cérébraux associées aux dysplasies corticales visibles en IRM Vingt deux patients suivis pour épilepsie pharmaco-résistante, porteurs d’une dysplasie corticale (18 frontales, 3 pariétales, 1 temporale) présentant des caractéristiques typiques en IRM (hypersignal FLAIR + épaississement cortical) et confirmée en anatomo-pathologie. Comparaison à 13 sujets sains sans antécédent neurologique. Analyse de la morphologie des sillons à partir de l’acquisition volumique Tl (Anatomist / Brainvisa 3.1, CEA, Orsay, France) et caractérisation des atypies sulcales. Quatre vingt six % des patients (19/22) présentait des atypies sulcales à proximité de la lésion dysplasique. Cette atypie concernait soit la morphologie (forme, nombre d’intersection), soit la profondeur du sillon concerné. Dans la sous-population des dysplasies précentrales (n = 8), tous les patients présentaient une ramification inhabituelle de la scissure centrale, contre 50% chez les contrôles (6/12). Chez les patients, cette ramification présentait des critères d’atypie (position, morphologie, profondeur), non retrouvée chez les sujets sains. Les dysplasies corticales sont souvent associées à une atypie sulcale. Le dépistage de ces anomalies grâce à l’analyse des sillons pourrait aider au diagnostic de dysplasies non visibles sur les séquences conventionnelles