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Relationship Between Cortical Resection and Visual Function After Occipital Lobe Epilepsy Surgery

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Relationship Between Cortical Resection and Visual Function After Occipital Lobe Epilepsy Surgery CLINICAL ARTICLE J Neurosurg 129:524–532, 2018 Relationship between cortical resection and visual function after occipital lobe epilepsy surgery *Won Heo, MD,1–4 June Sic Kim, PhD,5 Chun Kee Chung, MD, PhD,1–5 and Sang Kun Lee, MD, PhD3,4,6 Departments of 1Neurosurgery and 6Neurology, Seoul National University College of Medicine; 2Department of Neurosurgery and 4Clinical Research Institute, Seoul National University Hospital; 3Neuroscience Research Institute, Seoul National University Medical Research Center; and 5Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, South Korea OBJECTIVE In this study, the authors investigated long-term clinical and visual outcomes of patients after occipital lobe epilepsy (OLE) surgery and analyzed the relationship between visual cortical resection and visual function after OLE surgery. METHODS A total of 42 consecutive patients who were diagnosed with OLE and underwent occipital lobe resection between June 1995 and November 2013 were included. Clinical, radiological, and histopathological data were reviewed retrospectively. Seizure outcomes were categorized according to the Engel classification. Visual function after surgery was assessed using the National Eye Institute Visual Functioning Questionnaire 25. The relationship between the re- sected area of the visual cortex and visual function was demonstrated by multivariate linear regression models. RESULTS After a mean follow-up period of 102.2 months, 27 (64.3%) patients were seizure free, and 6 (14.3%) patients had an Engel Class II outcome. Nineteen (57.6%) of 33 patients had a normal visual field or quadrantanopia after surgery (normal and quadrantanopia groups). Patients in the normal and quadrantanopia groups had better vision-related quality of life than those in the hemianopsia group. The resection of lateral occipital areas 1 and 2 of the occipital lobe was sig- nificantly associated with difficulties in general vision, peripheral vision, and vision-specific roles. In addition, the resec- tion of intraparietal sulcus 3 or 4 was significantly associated with decreased social functioning. CONCLUSIONS The authors found a favorable seizure control rate (Engel Class I or II) of 78.6%, and 57.6% of the sub- jects had good visual function (normal vision or quadrantanopia) after OLE surgery. Lateral occipital cortical resection had a significant effect on visual function despite preservation of the visual field. https://thejns.org/doi/abs/10.3171/2017.5.JNS162963 KEY WORDS occipital lobe epilepsy; clinical outcome; visual field; visual function; resection frequency map CCIPITAL lobe epilepsy (OLE) accounts for a small of occipital or temporal lobe origin is difficult.3 Delineat- proportion of extratemporal epilepsies,4 and ac- ing the seizure-onset zone in the occipital lobe is difficult cording to previous studies, it constitutes 2%–13% because of rapid seizure propagation from the occipital Oof symptomatic partial epilepsies.2,3,7,16,26 Occipital lobe lobe to the frontal lobe and adjacent temporal and parietal seizures are characterized by visual auras and/or elemen- lobes, as well as to the midbrain tegmentum.6 For these tary visual hallucinations, ictal blindness, eye blinking, reasons, in the absence of occipital lesions found with im- ictal nystagmus, and eye deviation.1,15,19 However, deter- aging studies, it can be very difficult to distinguish OLE mining whether seizures associated with visual aura are from other epilepsies.6,18,19,23 ABBREVIATIONS AED = antiepileptic drug; CD = cortical dysplasia; EEG = electroencephalography; IPS = intraparietal sulcus; LO = lateral occipital area; NEI-VFQ-25 = National Eye Institute Visual Functioning Questionnaire 25; OLE = occipital lobe epilepsy; PPC = posterior parietal cortex; ROI = region of interest. SUBMITTED November 28, 2016. ACCEPTED May 8, 2017. INCLUDE WHEN CITING Published online October 27, 2017; DOI: 10.3171/2017.5.JNS162963. * Drs. Heo and Kim contributed equally to this work. 524 J Neurosurg Volume 129 • August 2018 ©AANS 2018, except where prohibited by US copyright law Unauthenticated | Downloaded 10/04/21 06:45 AM UTC Visual function after OLE surgery gery and to analyze the relationship between visual corti- cal resection and visual function after OLE surgery. Methods Patients and Diagnosis A total of 42 consecutive patients who were diagnosed with OLE and underwent occipital lobe resection at Seoul National University Hospital between June 1995 and No- vember 2013 were included in the study (Fig. 1). All of the patients had medically intractable epilepsy despite adequate anticonvulsant medication (antiepileptic drugs [AEDs]). The postoperative follow-up duration for each patient was more than 2 years. The decision to perform surgery was made for patients with the presence of a discrete lesion found with MRI with compatible video electroencephalography (EEG) moni- toring or, for patients without a lesion, an ictal-onset zone confirmed by intracranial EEG. In 36 patients, subdural electrodes were implanted to cover the presumed ictal-on- set zone according to preoperative evaluations, including video-EEG monitoring. After the electrodes were implant- ed, video-electrocorticographic monitoring was performed FIG. 1. Analysis flow chart. A total of 1281 epilepsy surgeries, with the until at least 3 typical seizures occurred. In the other 6 pa- exception of invasive monitoring and vagus nerve stimulation, were tients, whose lesions were seen with MRI, we performed performed at Seoul National University Hospital between June 1995 and a lesionectomy when the results of ictal scalp EEG and November 2013. Occipital lobe resection was performed in 64 patients. Among them, 13 with multifocal epilepsy were excluded, and 7 who un- semiology correlated well with the location of the lesion. derwent multiple operations were excluded. Two patients were excluded Preoperative and postoperative MR images were avail- because their follow-up period was less than 2 years. Finally, 42 patients able for 36 of the 42 patients included in the study. The with OLE were included in the study. Preoperative and postoperative resection areas in the remaining 6 patients who had under- MRI scans were available for 36 of the 42 patients; hence, the resection gone an occipital lobectomy before 1998 were identified frequency map was restricted to these 36 patients. The results of preop- through operative records. Use of the resection frequen- erative and postoperative visual field tests of 39 patients were available. cy map was restricted to a subgroup of 36 patients. This Three other patients were not subjected to visual field tests because they were too young (2, 2, and 5 years old) to undergo a precise visual study was approved by the institutional review board of field examination. The NEI-VFQ-25 was conducted retrospectively for the Seoul National University Hospital Clinical Research the study, and 15 people could not be contacted. We received a ques- Institute (Approval H-1506-089-681), and each participant tionnaire from 27 patients postoperatively. The other 15 patients were gave written informed consent. excluded from visual function analysis. Demographic and Clinical Data Demographic and clinical data, such as sex, age at sur- Visual field defects, which can occur after OLE sur- gery, seizure duration, monthly seizure frequency, seizure gery, are a considerable problem.4,10,20,23 However, studies semiology, presence of aura, number of preoperative AEDs that qualitatively or quantitatively address visual field de- prescribed, resection area, operation duration, length of fects after OLE surgery have been rare, because OLE is hospital stay, and follow-up duration, were reviewed in the infrequent and not easy to diagnose, and surgical treat- electronic medical records. The type of surgery and resec- ment of OLE is rare. Furthermore, visual function is as tion area were identified using postresection MRI. Seizure important an issue as visual field defects. Previous stud- outcomes after surgery were classified according to the ies categorized human visual cortical areas according to Engel classification method.8 The results of visual field visual function. Probabilistic maps of visual topography tests for 39 patients were available. Goldmann21 perimetry have been generated using standard functional MRI para- was used to test the visual field of 34 patients. The results digms.22 We believe that other approaches to sparing vi- of visual field testing for the other 5 patients were obtained sual function are required; thus, it would be meaningful by confrontation examination. Three other patients were to identify changes in visual function according to visual excluded from the analysis of visual field changes because cortical resection. To our knowledge, confirmation of the they were too young to undergo precise visual field exami- relationship between visual function and visual cortical nation. According to their visual field outcome, we cat- resection has not been attempted in this manner. In this egorized the patients into 1 of 4 groups, normal, quadran- study, we aimed to identify visual field changes after OLE tanopia, hemianopia, or other type of visual field defect. surgery and then evaluate changes in visual function that Visual function after surgery was assessed in 27 patients control the effect of visual field defects. using the National Eye Institute Visual Functioning Ques- Therefore, the purposes of this study were to determine tionnaire
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