Acta neurol. scandinav. 53, 335-357, 1976
University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
TEMPORAL LOBE EPILEPSY
Types of Seizures, Age, and Surgical Results
INGEJENSEN ABSTRACT Types of seizures, age a t onset of epilepsy, preoperative duration of epilepsy, and age at operation were studied in the literature and in 74 patients who underwent unilateral temporal lobe resection in 19601969 in Denmark. The medical and surgical series were compared. The age at onset was significantly lower in the surgical series. Prognostically favourable factors were : i) preoperative presence of a single type of seizure; ii) duration of epilepsy of less than 4 years, and in grand ma1 epilepsy of less than 1 year; iii) operation for epilepsy in o r beforc early adulthood. Prognostically unfavourable factors were : i ) preoperative presence of grand m a l ; i i ) age a t onset of epilepsy o r of the first grand ma1 seizure between 5 and 20 years; iii) preoperative duration of psychomotor cpilepsy over 10 years.
During the years 1960-1969, 74 patients with temporal lobe epilepsy, resistant to medication, underwent unilateral temporal lobe resection at Rigshospitalet, Copenhagen. A follow-up investigation in 1970-1971 (Inge Jensen 1975, Znge Jensen & Vaernet 1976) disclosed that 61 per cent were free from a n y seizures, 20 per cent had obtained a reduction i n seizure frequency of a t least 75 per cent, and the remaining 19 per cent ( i n the following denoted “no change”) comprised five patients with a reduction in their seizure frequency of 50-75 per cent, five patients with slight or no change, and four patients who died postoperatively. Thirty-two per cent of the patients (24/74) were described a s being mentally abnormal before the onset of epilepsy, and the time of the operation 85 per cent (63/74) displayed some psychiatric disorder. I n this investigation congenital impairment of intellectual function is This study was supported by a grant from the Danish Foundation for the Advancement of Medical Science and from the Danish Epilepsy Association.
Table i. Effect o f temporal lobe resection on seizures versus psgchiatric status at f o l l o w - u p .
Effect of operation
No seizures
Marked reduction
reduction
no.
yo
no.
yo
no.
Nochange
yo
no.
Dead
To
no.
0 20
-
0 0 0
Total no.
yo
-
22 20 5
30 27 7
Psuchiatric status Norm a1 Markedly improved Improved Unchanged/ deteriorated
15 13 3
33 29 7
6 5 1
40 33 7
0 1 1
20 2 0
1 1 0
14
31
3
20
3
60
3
60
4
100
27
36
Total
45
61
15
20
5
7
5
7
4
5
74
100
2
not considered a psychiatric disorder. At follow-up a total of 22 patients (i.e. 30 per cent) were without psychiatric disorders; of the 11 patients described as normal at operation, five were still considered to be so, while six had deteriorated. There was found to be a close interrelation between the psychiatric status at follow-up and a satisfactory reduction in, or abolition of, seizures (Table 1 ) . Ninety-five per cent (21/22) of those patients without psychiatric disorders had no or very few seizures as compared to 75 per cent (39/52) of the patients with some psychiatric disorder. This difference is significant at the 5 per cent level (0.0253). Only two-thirds of the 32 patients who were still psychiatrically abnormal postoperatively, or who deteriorated, were free o r almost free from seizures at follow-up, compared with 93 per cent of the patients who were psychiatrically markedly improved or remained normal. This difference is even more distinct and statistically significant at the 1 per cent level (0.0037). These variations in the interrelations between the operative effect on seizures and the psychiatric status at follow-up prompted me to investigate the correlations between these factors and the following variables : types of seizures, age a t onset of epilepsy, preoperative duration of epilepsy and age at operation. TYPES OF SEIZURES Literature Medical series. Previous surveys of patients with temporal lobe epilepsy treated medically indicate an incidence of associated grand ma1 ranging from 42 to 88 per cent (Gastaut & Gastaut (1951) 72 per cent; Hassan et al. (1966) 42 per cent; Ounsted et al. (1966) 88 per cent; and Lennox h Lennox (1960) 63 per cent).
Lennox & Lennox (1960) further recorded that grand ma1 preceded psychomotor epilepsy in 46 per cent of the patients, and in a total of 16 per cent the interval between the onset of grand ma1 and the onset of psychomotor seizures was 10 years or more. Currie et al. (1971), i n their 666 patients with temporal lobe epilepsy, recorded 514 patients with major fits, and of these 379 suffered from grand ma1 and 340 from psychomotor attacks; i.e. 205 patients had both grand ma1 and psychomotor epilepsy. Surgical series. In the surveys on patients with temporal lobe epilepsy treated with unilateral temporal lobe resection the incidence of grand ma1 epilepsy shows a similarly wide scatter (Morris (1956) 92 per cent; Paillas (1958) 52 per cent; Bailey (1961) 83 per cent; Falconer & Serafetinides (1963) 58 per cent; and Stepieh et al. (1969) 87 per cent). Furthermore, Davis (1963) reported that 20 of his 30 patients had grand ma1 as the initial type of seizure, as well as onset of epilepsy in the prepubertal period. The prognostic value of the preoperative presence of various types of seizures, apart from psychomotor seizures, has been elucidated in the surveys mentioned below, but the findings are not directly comparable. Morris (1956) i n his 36 patients found that only one of the seven patients with both petit ma1 and grand ma1 seizures was free from any seizures a t the postoperative follow-up, as compared to half of the 26 patients with grand ma1 alone. Paillas (1958) recorded that 46 per cent (11/24) of the patients without grand ma1 were free from any seizures at follow-up, compared with 35 per cent (9/26) of those suffering from grand mal. In the survey by Falconer & Serafetinides (1963) the figures are 57 per cent (22/42) and 50 per cent (29/58), respectively, but these refer to patients with no or only a few seizures. Stepieh e t al. (1969), i n their series of 55 patients, found that the seven patients with “pure” temporal lobe seizures were cured; when seizures were “mixed”, good results were obtained in 52 per cent (17/33), and i n patients with seizures without clinically temporal character good results were obtained in 43 per cent (7/15). Bidzihski (1971), studying the same patients, concluded that specially good operative results were obtained i n patients with seizures exclusively of temporal origin, even if these tended to generalize. Bengzon et al. (1968), from 547 patients operated upon between 1953 and 1960 a t Montreal Neurological Institute, compared a selected group of “surgical successes” with a selected group of “surgical failures” each group comprising 50 patients. As statistically significant factors they found that more patients, i.e. 70 per cent of the “unsuccessful group”, bad extratemporal features i n their seizure patterns and a much higher frequency of generalized seizures. This applied to only 30 per cent in the “successful group”.
Present lnvestigation The various types of seizures afflicting the patients before the temporal lobe resection in the Danish case material can be divided into: I ) phychomotor epilepsy: a rich variety of attacks, all of “temporal” character, which have been described in detail elsewhere (Znge Jensen h Vaernet 1976), 11) focal motor or sensory attacks, including Jacksonian epilepsy, 111) grand mal, and IV) petit ma1 (Table 2 ) . All but one of the patients suffered from psychomotor epilepsy. This
41 5
13
4
7 9
20
-
-
36
5 20
7
18 8 10
no.
63
32 45
49
40 53 71
%
Psychomotor and grand mal
1 4
5
-
-
-
19
11
-
5
%
-
no.
Ps~chomotor and/or focal
27 13
YO
9 1
14
Total
Psychiatric status Normal Markedly improved Unchanged/ deteriorated
12 2 -
no.
psychomotor
No seizures Marked reduction No change
Effect of operation
6
5 6
17
9 5 3
no.
19
23 30
23
20 33 21
%
Psychomotor grand ma1 and focal
2
-
-
2
1
1
-
no.
6
-
3
7
32
22 20
74
45 15 14
a
__
no.
%
Psychomotor grand ma1 and petit ma1
Table 2. Types of seizures correlated to effect of operation and psychiatric status a t follow-up.
Total
43
30 27
100
61 20 19
96
co
0 0
patient, Case no. 2 in the series, had only focal motor seizures, and a temporal 11G focus. Only two patients had petit mal, Case nos 10 and 11 in the series; one of them was cured of his seizures, but some years after the operation developed a schizophrenia-like psychosis with self-mutilation and attempted suicide. The occurrence of only a single type of epilepsy is prognostically favourable as regards relief from seizures ; this finding is statistically significant at the 1 per cent level (0.0087). Preoperative presence of grand ma1 is prognostically highly unfavourable as regards postoperative relief from seizures: only 51 per cent (28/55) of the patients with grand ma1 were free from any seizures at follow-up, as compared to 89 per cent (17/19) of the patients without grand ma1 (Table 31. This difference is significant at the 0.5 per cent level. Table 3. The presence of grand ma1 epilepsy correlated to effect o f operation and psychiatric status a t follow-up.
Effect of operation No seizures Seizures no. 70 no. TO
Psychiatric status Normal Abnormal no. To no. ?6
No grand ma1
28 17
51 89'
27 2
49 11
12 10
22 53
43 9
78 47
Total
45
61 P
29
39
22
30 P
< 0.05
52
70
Grand ma1
< 0.01
Total
I I
no.
%
55 19
74 26
74
100
Table 4 . Initial tgpe of seizure correlated to effect of operation and psgehiatric status a t follow-up.
Effect of operation No seizures Seizures TO no. TO no. Psychomotor Grand ma1 Total
1
20 8
63 35
12 15
37 65
28
51
27
49
Psychiatric status Normal .4bnormal TO no. TO no.
I
9 3
28 13
23 20
72 a7
12
22
43
78
Total
J
no.
%
32 23
58 42
55
100
Patients w i t h both psychomotor and grand ma1 epilepsy. In 32 patients the initial attack of their chronic epilepsy was of psychomotor character, and 63 per cent (20/32) of these patients were seizure-free at follow-up (Table 4 ) . Only 35 per cent (8/23) of the patients in whom the grand ma1 epilepsy preceded the psychomotor epilepsy were seizure-free at follow-up. This difference just falls short of statistical significance at the 5 per cent level. Onset in psychomotor epilepsy also seems to influence the psychiatric status at follow-up favourably, but this trend is not significant. Table 5. Effect of temporal lobe resection in 55 patients w i t h grand ma1 epilepsy and psychomotor epilepsy correlated t o duration of initial type before onset o f the second t y p e .
Duration in years
2 0 years ------20I----------------
10
15 I
Gastaut & Gastaut (1951):
4 11 -4 1 -1 -1 9 --[ 100patients Lennox & Lennox (1960): 3 1 2 7 -0 362 patients Hassan et al. (1966): 135patients 1-5 2-1 Aird et al. (1967): 193patients 32-1-53-+- -24-1 Vorobiev (1968): 200patients 17 -1 + ]-20+1 -9
57-1
Mathai & Chandy (1970): 31patients 11 -69 -12 -61 -5 -8 Currie et al. (1971) : 604patients 87-1-22-1 Table 6 B. Age at onset of temporal lobe epilepsy ( i n percentage). Surgical series.
> 20 years _______5I------10I -_-----15I---_---20I-------------
0
I
Paillas (1958): 50 patients
/ - 1 4 - + - 1 - 5 8 ~ 1 ~ 2 8
Falconer & Serafetinides (1963): 100patients ~-43--q-33--+Davis (1963): -
30 patients
1 5 -0
24 P-- 1
~
3
7
-
w
I
~
1
Bengzon et al. (1968): 100patients ~~53--+-22-+--25StepieA et al. (1969): 54 patients
[-46------91-32-1-22-
Mathai & Chandy (1970): 24 patients /-46--12)-335----P/-21Currie et al. (1971) : 62 patients
1-68-1732
lnge Jensen (1975): 74 patients
1 ~ 4 8 - - - - - - f - 1 - 4 1 ~ 1 ~ 1 1
3
343 result as compared to only 30 per cent (6/20) of the patients with later onset. Bengzon et al. (1968), in their highly selected case material, found that the age at onset of seizures was a prognostic factor of no statistical significance.
Present Investigation In the Danish survey the age a t onset of epilepsy h a s been regarded as the age a t which the patient experienced his or her first attack in the chronic epilepsy. This implies that, for example, febrile convulsions and single convulsions of other known aetiology have been disregarded. Table 7 . Age a t o n s e t of epilepsg in 74 t e m p o r a l lobe resected p a t i e n t s . Years
No. of patients Cumulative percentage
University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
TEMPORAL LOBE EPILEPSY
Types of Seizures, Age, and Surgical Results
INGEJENSEN ABSTRACT Types of seizures, age a t onset of epilepsy, preoperative duration of epilepsy, and age at operation were studied in the literature and in 74 patients who underwent unilateral temporal lobe resection in 19601969 in Denmark. The medical and surgical series were compared. The age at onset was significantly lower in the surgical series. Prognostically favourable factors were : i) preoperative presence of a single type of seizure; ii) duration of epilepsy of less than 4 years, and in grand ma1 epilepsy of less than 1 year; iii) operation for epilepsy in o r beforc early adulthood. Prognostically unfavourable factors were : i ) preoperative presence of grand m a l ; i i ) age a t onset of epilepsy o r of the first grand ma1 seizure between 5 and 20 years; iii) preoperative duration of psychomotor cpilepsy over 10 years.
During the years 1960-1969, 74 patients with temporal lobe epilepsy, resistant to medication, underwent unilateral temporal lobe resection at Rigshospitalet, Copenhagen. A follow-up investigation in 1970-1971 (Inge Jensen 1975, Znge Jensen & Vaernet 1976) disclosed that 61 per cent were free from a n y seizures, 20 per cent had obtained a reduction i n seizure frequency of a t least 75 per cent, and the remaining 19 per cent ( i n the following denoted “no change”) comprised five patients with a reduction in their seizure frequency of 50-75 per cent, five patients with slight or no change, and four patients who died postoperatively. Thirty-two per cent of the patients (24/74) were described a s being mentally abnormal before the onset of epilepsy, and the time of the operation 85 per cent (63/74) displayed some psychiatric disorder. I n this investigation congenital impairment of intellectual function is This study was supported by a grant from the Danish Foundation for the Advancement of Medical Science and from the Danish Epilepsy Association.
Table i. Effect o f temporal lobe resection on seizures versus psgchiatric status at f o l l o w - u p .
Effect of operation
No seizures
Marked reduction
reduction
no.
yo
no.
yo
no.
Nochange
yo
no.
Dead
To
no.
0 20
-
0 0 0
Total no.
yo
-
22 20 5
30 27 7
Psuchiatric status Norm a1 Markedly improved Improved Unchanged/ deteriorated
15 13 3
33 29 7
6 5 1
40 33 7
0 1 1
20 2 0
1 1 0
14
31
3
20
3
60
3
60
4
100
27
36
Total
45
61
15
20
5
7
5
7
4
5
74
100
2
not considered a psychiatric disorder. At follow-up a total of 22 patients (i.e. 30 per cent) were without psychiatric disorders; of the 11 patients described as normal at operation, five were still considered to be so, while six had deteriorated. There was found to be a close interrelation between the psychiatric status at follow-up and a satisfactory reduction in, or abolition of, seizures (Table 1 ) . Ninety-five per cent (21/22) of those patients without psychiatric disorders had no or very few seizures as compared to 75 per cent (39/52) of the patients with some psychiatric disorder. This difference is significant at the 5 per cent level (0.0253). Only two-thirds of the 32 patients who were still psychiatrically abnormal postoperatively, or who deteriorated, were free o r almost free from seizures at follow-up, compared with 93 per cent of the patients who were psychiatrically markedly improved or remained normal. This difference is even more distinct and statistically significant at the 1 per cent level (0.0037). These variations in the interrelations between the operative effect on seizures and the psychiatric status at follow-up prompted me to investigate the correlations between these factors and the following variables : types of seizures, age a t onset of epilepsy, preoperative duration of epilepsy and age at operation. TYPES OF SEIZURES Literature Medical series. Previous surveys of patients with temporal lobe epilepsy treated medically indicate an incidence of associated grand ma1 ranging from 42 to 88 per cent (Gastaut & Gastaut (1951) 72 per cent; Hassan et al. (1966) 42 per cent; Ounsted et al. (1966) 88 per cent; and Lennox h Lennox (1960) 63 per cent).
Lennox & Lennox (1960) further recorded that grand ma1 preceded psychomotor epilepsy in 46 per cent of the patients, and in a total of 16 per cent the interval between the onset of grand ma1 and the onset of psychomotor seizures was 10 years or more. Currie et al. (1971), i n their 666 patients with temporal lobe epilepsy, recorded 514 patients with major fits, and of these 379 suffered from grand ma1 and 340 from psychomotor attacks; i.e. 205 patients had both grand ma1 and psychomotor epilepsy. Surgical series. In the surveys on patients with temporal lobe epilepsy treated with unilateral temporal lobe resection the incidence of grand ma1 epilepsy shows a similarly wide scatter (Morris (1956) 92 per cent; Paillas (1958) 52 per cent; Bailey (1961) 83 per cent; Falconer & Serafetinides (1963) 58 per cent; and Stepieh et al. (1969) 87 per cent). Furthermore, Davis (1963) reported that 20 of his 30 patients had grand ma1 as the initial type of seizure, as well as onset of epilepsy in the prepubertal period. The prognostic value of the preoperative presence of various types of seizures, apart from psychomotor seizures, has been elucidated in the surveys mentioned below, but the findings are not directly comparable. Morris (1956) i n his 36 patients found that only one of the seven patients with both petit ma1 and grand ma1 seizures was free from any seizures a t the postoperative follow-up, as compared to half of the 26 patients with grand ma1 alone. Paillas (1958) recorded that 46 per cent (11/24) of the patients without grand ma1 were free from any seizures at follow-up, compared with 35 per cent (9/26) of those suffering from grand mal. In the survey by Falconer & Serafetinides (1963) the figures are 57 per cent (22/42) and 50 per cent (29/58), respectively, but these refer to patients with no or only a few seizures. Stepieh e t al. (1969), i n their series of 55 patients, found that the seven patients with “pure” temporal lobe seizures were cured; when seizures were “mixed”, good results were obtained in 52 per cent (17/33), and i n patients with seizures without clinically temporal character good results were obtained in 43 per cent (7/15). Bidzihski (1971), studying the same patients, concluded that specially good operative results were obtained i n patients with seizures exclusively of temporal origin, even if these tended to generalize. Bengzon et al. (1968), from 547 patients operated upon between 1953 and 1960 a t Montreal Neurological Institute, compared a selected group of “surgical successes” with a selected group of “surgical failures” each group comprising 50 patients. As statistically significant factors they found that more patients, i.e. 70 per cent of the “unsuccessful group”, bad extratemporal features i n their seizure patterns and a much higher frequency of generalized seizures. This applied to only 30 per cent in the “successful group”.
Present lnvestigation The various types of seizures afflicting the patients before the temporal lobe resection in the Danish case material can be divided into: I ) phychomotor epilepsy: a rich variety of attacks, all of “temporal” character, which have been described in detail elsewhere (Znge Jensen h Vaernet 1976), 11) focal motor or sensory attacks, including Jacksonian epilepsy, 111) grand mal, and IV) petit ma1 (Table 2 ) . All but one of the patients suffered from psychomotor epilepsy. This
41 5
13
4
7 9
20
-
-
36
5 20
7
18 8 10
no.
63
32 45
49
40 53 71
%
Psychomotor and grand mal
1 4
5
-
-
-
19
11
-
5
%
-
no.
Ps~chomotor and/or focal
27 13
YO
9 1
14
Total
Psychiatric status Normal Markedly improved Unchanged/ deteriorated
12 2 -
no.
psychomotor
No seizures Marked reduction No change
Effect of operation
6
5 6
17
9 5 3
no.
19
23 30
23
20 33 21
%
Psychomotor grand ma1 and focal
2
-
-
2
1
1
-
no.
6
-
3
7
32
22 20
74
45 15 14
a
__
no.
%
Psychomotor grand ma1 and petit ma1
Table 2. Types of seizures correlated to effect of operation and psychiatric status a t follow-up.
Total
43
30 27
100
61 20 19
96
co
0 0
patient, Case no. 2 in the series, had only focal motor seizures, and a temporal 11G focus. Only two patients had petit mal, Case nos 10 and 11 in the series; one of them was cured of his seizures, but some years after the operation developed a schizophrenia-like psychosis with self-mutilation and attempted suicide. The occurrence of only a single type of epilepsy is prognostically favourable as regards relief from seizures ; this finding is statistically significant at the 1 per cent level (0.0087). Preoperative presence of grand ma1 is prognostically highly unfavourable as regards postoperative relief from seizures: only 51 per cent (28/55) of the patients with grand ma1 were free from any seizures at follow-up, as compared to 89 per cent (17/19) of the patients without grand ma1 (Table 31. This difference is significant at the 0.5 per cent level. Table 3. The presence of grand ma1 epilepsy correlated to effect o f operation and psychiatric status a t follow-up.
Effect of operation No seizures Seizures no. 70 no. TO
Psychiatric status Normal Abnormal no. To no. ?6
No grand ma1
28 17
51 89'
27 2
49 11
12 10
22 53
43 9
78 47
Total
45
61 P
29
39
22
30 P
< 0.05
52
70
Grand ma1
< 0.01
Total
I I
no.
%
55 19
74 26
74
100
Table 4 . Initial tgpe of seizure correlated to effect of operation and psgehiatric status a t follow-up.
Effect of operation No seizures Seizures TO no. TO no. Psychomotor Grand ma1 Total
1
20 8
63 35
12 15
37 65
28
51
27
49
Psychiatric status Normal .4bnormal TO no. TO no.
I
9 3
28 13
23 20
72 a7
12
22
43
78
Total
J
no.
%
32 23
58 42
55
100
Patients w i t h both psychomotor and grand ma1 epilepsy. In 32 patients the initial attack of their chronic epilepsy was of psychomotor character, and 63 per cent (20/32) of these patients were seizure-free at follow-up (Table 4 ) . Only 35 per cent (8/23) of the patients in whom the grand ma1 epilepsy preceded the psychomotor epilepsy were seizure-free at follow-up. This difference just falls short of statistical significance at the 5 per cent level. Onset in psychomotor epilepsy also seems to influence the psychiatric status at follow-up favourably, but this trend is not significant. Table 5. Effect of temporal lobe resection in 55 patients w i t h grand ma1 epilepsy and psychomotor epilepsy correlated t o duration of initial type before onset o f the second t y p e .
Duration in years
2 0 years ------20I----------------
10
15 I
Gastaut & Gastaut (1951):
4 11 -4 1 -1 -1 9 --[ 100patients Lennox & Lennox (1960): 3 1 2 7 -0 362 patients Hassan et al. (1966): 135patients 1-5 2-1 Aird et al. (1967): 193patients 32-1-53-+- -24-1 Vorobiev (1968): 200patients 17 -1 + ]-20+1 -9
57-1
Mathai & Chandy (1970): 31patients 11 -69 -12 -61 -5 -8 Currie et al. (1971) : 604patients 87-1-22-1 Table 6 B. Age at onset of temporal lobe epilepsy ( i n percentage). Surgical series.
> 20 years _______5I------10I -_-----15I---_---20I-------------
0
I
Paillas (1958): 50 patients
/ - 1 4 - + - 1 - 5 8 ~ 1 ~ 2 8
Falconer & Serafetinides (1963): 100patients ~-43--q-33--+Davis (1963): -
30 patients
1 5 -0
24 P-- 1
~
3
7
-
w
I
~
1
Bengzon et al. (1968): 100patients ~~53--+-22-+--25StepieA et al. (1969): 54 patients
[-46------91-32-1-22-
Mathai & Chandy (1970): 24 patients /-46--12)-335----P/-21Currie et al. (1971) : 62 patients
1-68-1732
lnge Jensen (1975): 74 patients
1 ~ 4 8 - - - - - - f - 1 - 4 1 ~ 1 ~ 1 1
3
343 result as compared to only 30 per cent (6/20) of the patients with later onset. Bengzon et al. (1968), in their highly selected case material, found that the age at onset of seizures was a prognostic factor of no statistical significance.
Present Investigation In the Danish survey the age a t onset of epilepsy h a s been regarded as the age a t which the patient experienced his or her first attack in the chronic epilepsy. This implies that, for example, febrile convulsions and single convulsions of other known aetiology have been disregarded. Table 7 . Age a t o n s e t of epilepsg in 74 t e m p o r a l lobe resected p a t i e n t s . Years
No. of patients Cumulative percentage
