title: Epilepsy surgery in patients with normal or nonfocal MRI scans: integrative strategies offer long-term seizure relief.
abstract: OBJECTIVE
  Excisional surgery achieves seizure freedom in a large proportion of children with intractable lesional epilepsy, but the outcome for children without a focal lesion on MRI is less clear. We report the outcome of a cohort predominantly of children with nonlesional intractable partial epilepsy undergoing resective surgery.
  
  
  METHODS
  We studied 102 patients with nonlesional intractable partial epilepsy who underwent excisional surgery. The epileptogenic region was identified by integrating clinical exam and video-EEG data complemented by ictal SPECT (n = 40), PET (n = 10), extraoperative subdural monitoring (n = 80), and electrocorticography (n = 22). All patients had follow-up greater than 2 years, 76 patients had 5-year follow-up, and 43 patients had 10-year follow-up.
  
  
  RESULTS
  A total of 66 resections were unilobar; 36 were multilobar. One patient died of causes unrelated to seizures or surgery. At 2-year follow-up, 44 of 101 patients were seizure-free, 15 experienced >90% reduction, 17 had >50% reduction, and 25 were unchanged. At 5-year follow-up, 35 of 76 patients were seizure-free, 12 experienced >90% reduction, 12 had >50% reduction, and 17 were unchanged. At 10-year follow-up, 16 of 43 patients were seizure-free, 13 experienced >90% reduction, 7 had >50% reduction, and 7 were unchanged. Outcomes correlated with the presence of convergent focal interictal spikes (p < 0.005) on the scalp EEG and completeness of resection (p < 0.0005).
  
  
  CONCLUSIONS
  Our findings demonstrate that excisional surgery is successful in the majority of children with nonlesional partial epilepsy. A multimodal integrative approach can minimize the size of resection and alleviate the need for invasive EEG monitoring. Focal interictal spikes and completeness of resection predict good outcome. The benefits of surgery are long-lasting.
authors.affiliation: Department of Neurology, Miami Children's Hospital, Miami, FL, USA. prasanna.jayakar@mch.com
authors.forename: Prasanna
authors.initials: P
authors.lastname: Jayakar
authors.forename: Catalina
authors.initials: C
authors.lastname: Dunoyer
authors.forename: Pat
authors.initials: P
authors.lastname: Dean
authors.forename: John
authors.initials: J
authors.lastname: Ragheb
authors.forename: Trevor
authors.initials: T
authors.lastname: Resnick
authors.forename: Glenn
authors.initials: G
authors.lastname: Morrison
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Bhatia
authors.forename: Michael
authors.initials: M
authors.lastname: Duchowny
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D001931:Brain Mapping; D002540:Cerebral Cortex / Q000473:pathology* / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D018572:Disease-Free Survival; D004569:Electroencephalography / Q000706:statistics & numerical data; D004828:Epilepsies, Partial / Q000175:diagnosis / Q000473:pathology* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008137:Longitudinal Studies; D008279:Magnetic Resonance Imaging / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008991:Monitoring, Physiologic; D017063:Outcome Assessment, Health Care; D049268:Positron-Emission Tomography; D011300:Preoperative Care; D012189:Retrospective Studies; D015899:Tomography, Emission-Computed, Single-Photon; D014743:Videotape Recording