Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

Nascimento, Fábio A.; Gatto, Luana Antunes Maranha; Silvado, Carlos; Mäder-Joaquim, Maria Joana; Moro, Marlus Sidney; Araujo, Joao Candido

doi:10.1590/0004-282X20150188

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Sumário

Articles • Arq. Neuro-Psiquiatr. 74 (1) • Jan 2016 • https://doi.org/10.1590/0004-282X20150188 copiar

Lobectomia temporal anterior versus amigdalohipocampectomia seletiva para epilepsia de lobo temporal mesial

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Objetivo

Contribuir com nossa experiência para o tratamento cirúrgico de pacientes com epilepsia do lobo temporal mesial submetidos a lobectomia temporal anterior (LTA) ou amigdalohipocampectomia seletiva (AHS).

Método

Estudo retrospectivo observacional. Foram incluídos pacientes com epilepsia refratária devido a esclerose mesial temporal unilateral, submetidos a LTA ou AHS no Hospital de Clínicas – UFPR, entre 2005-2012. Foram comparados os resultados cognitivos (análises de memórias verbal e visuoespacial), controle de crises (Engel) e complicações cirúrgicas.

Resultados

Sessenta e sete pacientes (33 LTA, 34 AHS) foram estudados; o período de acompanhamento médio foi de 64 meses. Não houve diferença no controle das crises ou resultado neuropsicológico, mas a memória verbal foi mais negativamente afetada nos pacientes submetidos à LTA no hemisfério dominante. Maior número de complicações graves ocorreu no grupo de LTA (p = 0.004).

Conclusão

Controle de crises e resultados neuropsicológicos não diferiram. LTA pareceu estar associada a um maior risco cirúrgico.

epilepsia do lobo temporal; epilepsia amígdalo-hipocampal; lobectomia temporal anterior; testes neuropsicológicos; crises convulsivas; complicações pós-operatórias

	SelAH (n = 34) n (%)	ATL (n = 33) n (%)	p-value	Total
Gender
Female	14 (41.18)	16 (48.48)	0.627	30
Male	20 (58.82)	17 (51.52)		37
Age at surgery (Ø)	33.4	37.6	0.136	35.46
Age at first seizure (Ø)	8.3	10.2	0.286	9.23
Duration of epilepsy (Ø)	25.4	27.4	0.552	26.38
Side of resection
Nondominant	15 (44.12)	18 (54.55)	0.467	33
Dominant	19 (55.88)	15 (45.45)		34
Handedness
Right	30 (88.24)	30 (90.91)	1	60
Left	3 (8.82)	2 (6.06)		5
Ambidextrous	1 (2.94)	1 (3.03)		2
Education level (Ø)	8.2	8	0.778	8.1
Systemic comorbidities	6	11	-	17
History of CNS infection	2	2	-	4
History of severe head trauma	2	2	-	4
Family history of epilepsy	2 (5.88)	1 (3.13)	1	3
Additional presurgical workup needed
Wada test	3 (8.82)	1 (3.03)	0.614	4
PET-CT	1 (2.94)	3 (9.09)	0.356	4
SPECT	2 (5.88)	1 (3.03)	1	3
Sphenoidal EEG	1 (2.94)	3 (9.09)	0.288	4
Number of AEDs at time of surgery
1	3 (8.82)	3 (9.09)	0.585	6
2	11 (32.35)	9 (27.27)		20
3	15 (44.12)	19 (57.58)		34
4	5 (14.71)	2 (6.06)		7
Histopathology
Mesial sclerosis	15	29		44
Normal	1	2		3
Not performed. Aspiration only	19	1		20
Hemorrhage only	0	1		1
Admission period (days)	8.7	11.5	0.537	10

	Verbal memory		Visuospatial memory		Verbal memory		Verbal memory

	SelAH n (%)	ATL n (%)	SelAH n (%)	ATL n (%)	ND side n (%)	Dom side n (%)	ND side n (%)	Dom side n (%)
Improvement	7 (20.6)	5 (15.2)	4 (12.1)	8 (24.2)	7 (21.2)	5 (14.7)	5 (15.2)	7 (20.6)
Worsening	9 (26.5)	14 (42.4)	2 (6.1)	0	11 (33.3)	12 (35.3)	0	2 (5.9)
Stability	18 (52.9)	14 (42.4)	27 (81.8)	25 (75.8)	15 (45.5)	17 (50.0)	28 (84.8)	25 (73.5)
Total	34	33	33	33	33	34	33	34
p-value	0.386		0.182		0.784		Not applicable

ATL	Verbal memory				Visuospatial memory

	Pre		Post		Pre		Post

	ND n (%)	Dom n (%)	ND n (%)	Dom n (%)	ND n (%)	Dom n (%)	ND n (%)	Dom n (%)
Normal	11 (61.11)	9 (60.00)	14 (77.78)	3 (20.00)	13 (72.22)	9 (60.00)	15 (83.33)	11 (73.33)
Mild	2 (11.11)	2 (13.33)	1 (5.56)	1 (6.67)	3 (16.67)	2 (13.33)	2 (11.11)	2 (13.33)
Moderate	2 (11.11)	1 (6.67)	1 (5.56)	3 (20.00)	2 (11.11)	4 (26.67)	1 (5.56)	2 (13.33)
Severe	3 (16.67)	3 (20.00)	2 (11.11)	8 (53.33)
Total	18	15	18	15	18	15	18	15

SelAH	Verbal memory				Visuospatial memory

	Pre		Post		Pre		Post

	ND n (%)	Dom n (%)	ND n (%)	Dom n (%)	ND n (%)	Dom n (%)	ND n (%)	Dom n (%)
Normal	13 (86.67)	8 (42.11)	9 (60.00)	12 (63.16)	12 (85.71)	18 (94.74)	12 (85.71)	18 (94.74)
Mild	1 (6.67)	1 (5.26)	0 (0.00)	1 (5.26)
Moderate	0 (0.00)	2 (10.53)	2 (13.33)	1 (5.26)	2 (14.29)	1 (5.26)	2 (14.29)	1 (5.26)
Severe	1 (6.67)	8 (42.11)	4 (26.67)	5 (26.32)
Total	15	19	15	19	14	19	14	19

Engel	6 months		1 year		2 years		3 years		4 years		5 years

	SelAH	ATL	SelAH	ATL	SelAH	ATL	SelAH	ATL	SelAH	ATL	SelAH	ATL
Ia	85.29	72.72	64.7	54.54	58.82	54.54	59.37	51.51	44.44	51.51	47.82	54.54
Ib	8.82	15.15	8.82	15.15	8.82	6.06	6.25	6.06	7.4	9.09	13.04	4.54
Ic	-	-	-	-	5.88	3.03	6.25	3.03	11.11	6.06	4.34	4.54
Id	-	-	14.7	6.06	8.82	9.09	12.5	6.06	11.11	-	8.69	-
IIa	-	-	8.82	12.12	14.7	9.09	6.25	9.09	11.11	6.06	13.04	4.54
IIb	-	6.06	-	6.06	-	3.03	-	-	-	-	-	-
IIc	-	-	-	-	-	-	3.12	3.03	7.4	3.03	4.34	4.54
IId	2.94	-	-	-	-	-	-	-	-	-	-	-
IIIa	2.94	6.06	2.94	6.06	2.94	12.12	3.12	15.15	3.7	12.12	4.34	9.09
IIIb	-	-	-	-	-	-	3.12	3.03	3.7	3.03	4.34	4.54
IVa	-	-	-	-	-	3.03	-	3.03	-	9.09	-	13.63
IVb	-	-	-	-	-	-	-	-	-	-	-	-
IVc	-	-	-	-	-	-	-	-	-	-	-	-
n	34	33	34	33	34	33	32	33	27	33	23	22
Median Classification	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ib	Ia	Ib	Ia
Minimum Classification	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ia	Ia
Maximum Classification	IIIa	IIIa	IIIa	IIIa	IIIa	IVa	IIIb	IVa	IIIb	IVa	IIIb	IVa
p-value	0.379		0.393		0.473		0.331		0.965		0.761

Assessment	Engel	SelAH		ATL		p-value

		n	%	n	%
6 months	Satisfactory	33	97.1	31	93.9	0.613
	Unsatisfactory	1	2.9	2	6.1
	Total	34	100.0	33	100.0
1 year	Satisfactory	33	97.1	31	93.9	0.613
	Unsatisfactory	1	2.9	2	6.1
	Total	34	100.0	33	100.0
2 years	Satisfactory	33	97.1	28	84.8	0.105
	Unsatisfactory	1	2.9	5	15.2
	Total	34	100.0	33	100.0
3 years	Satisfactory	32	100.0	33	100.0	1
	Unsatisfactory	0	0.0	0	0.0
	Total	32	100.0	33	100.0
4 years	Satisfactory	25	92.6	25	75.8	0.162
	Unsatisfactory	2	7.4	8	24.2
	Total	27	100.0	33	100.0
5 years	Satisfactory	21	91.3	16	72.7	0.135
	Unsatisfactory	2	8.7	6	27.3
	Total	23	100.0	22	100.0

Complications	SelAH (n/N)	ATL (n/N)	Total
Operative site infection / Meningitis	- 1 Operative site infection	- 3 Meningitis	8/67
	- 1 Abscesses	- 2 Abscesses
		- 1 Empyema + osteomyelitis
	2/34	6/33
Hemorrhage and/or Hematoma		- 1 Cerebellar hemorrhage	2/67
		- 1 Operative site hematoma
	0	2/33
Cerebrospinal fluid (CSF) related	- 1 CSF leak	- 2 CSF leaks	4/67
		- 1 Subdural hygroma
	1/34	3/33
Ischemic cerebrovascular accident (iCVA)	- 1 iCVA affecting left internal capsule = permanent hemiparesis	- 1 Left, transitory MCA ischemia (vasospasm)	4/67
		- 1 Ischemia in the left MCA territory = permanent deficits
		- 1 Ischemia in the right MCA territory due to edema = hemiparesis
	1/34	3/33
Neurological deficit	- 3 III CN palsies	- 4 III CN palsies	15/67
	- 2 Transitory dysnomias	- 2 Transitory dysphagias
	- 1 Permanent hemiplegia	- 1 Transitory hemiparesis
		- 1 Permanent hemiparesis
		- 1 Permanent hemiplegia
	6/34	9/33
transitory	5	7	12/67
permanent	1	2	3/67
	0	- 1 Ventilator-associated pneumonia	1/67
Systemic infection		1/33

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[1] Correpondence
: Fábio Augusto Nascimento e Silva; 5W-445; 399, Bathurst St. M5T 2S8; Toronto, Ontario, Canada; E-mail:nascimento.fabio.a@gmail.com