Stiftung Tierärztliche Hochschule Hannover (TiHo)

Association of piriform cortex resection with surgical outcomes in patients with temporal lobe epilepsy

ORCID
0000-0002-2307-071X
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Galovic, Marian;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Baudracco, Irene;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Wright-Goff, Evan;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Pillajo, Galo;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Nachev, Parashkev;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Wandschneider, Britta;
Affiliation
Magnetic Resonance Imaging Unit, Klinik Mara, Bethel Epilepsy Centre, Bielefeld, Germany.
Woermann, Friedrich;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Thompson, Pamela;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Baxendale, Sallie;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
McEvoy, Andrew W;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Nowell, Mark;
Affiliation
Translational Imaging Group, Centre for Medical Image Computing, Department of Medical Physics and Bioengineering, UCL, London, United Kingdom.
Mancini, Matteo;
Affiliation
Epilepsy Society MRI Unit, Epilepsy Society, Chalfont St Peter, United Kingdom.
Vos, Sjoerd B;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Winston, Gavin P;
ORCID
0000-0003-1553-7903
Affiliation
Translational Imaging Group, Centre for Medical Image Computing, Department of Medical Physics and Bioengineering, UCL, London, United Kingdom.
Sparks, Rachel;
Affiliation
Translational Imaging Group, Centre for Medical Image Computing, Department of Medical Physics and Bioengineering, UCL, London, United Kingdom.
Prados, Ferran;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Miserocchi, Anna;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
de Tisi, Jane;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Van Graan, Louis André;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Rodionov, Roman;
Affiliation
Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania.
Wu, Chengyuan;
Affiliation
Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania.
Alizadeh, Mahdi;
Affiliation
medical student at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Kozlowski, Lauren;
Affiliation
Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania.
Sharan, Ashwini D;
Affiliation
Center for Neuroengineering and Therapeutics, Department of Bioengineering, University of Pennsylvania, Philadelphia.
Kini, Lohith G;
Affiliation
Center for Neuroengineering and Therapeutics, Department of Bioengineering, University of Pennsylvania, Philadelphia.
Davis, Kathryn A;
Affiliation
Center for Neuroengineering and Therapeutics, Department of Bioengineering, University of Pennsylvania, Philadelphia.
Litt, Brian;
Affiliation
Translational Imaging Group, Centre for Medical Image Computing, Department of Medical Physics and Bioengineering, UCL, London, United Kingdom.
Ourselin, Sebastien;
Affiliation
Laboratory of Developmental Epilepsy, Saul R. Korey Department of Neurology, Montefiore/Einstein Epilepsy Management Center, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York.
Moshé, Solomon L;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Sander, Josemir W A;
ORCID
0000-0002-9648-8973
Affiliation
Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany.
Löscher, Wolfgang;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Duncan, John S;
Affiliation
UK National Institute for Health Research, University College London (UCL) Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom.
Koepp, Matthias J

Importance:A functional area associated with the piriform cortex, termed area tempestas, has been implicated in animal studies as having a crucial role in modulating seizures, but similar evidence is limited in humans. Objective:To assess whether removal of the piriform cortex is associated with postoperative seizure freedom in patients with temporal lobe epilepsy (TLE) as a proof-of-concept for the relevance of this area in human TLE. Design, Setting, and Participants:This cohort study used voxel-based morphometry and volumetry to assess differences in structural magnetic resonance imaging (MRI) scans in consecutive patients with TLE who underwent epilepsy surgery in a single center from January 1, 2005, through December 31, 2013. Participants underwent presurgical and postsurgical structural MRI and had at least 2 years of postoperative follow-up (median, 5 years; range, 2-11 years). Patients with MRI of insufficient quality were excluded. Findings were validated in 2 independent cohorts from tertiary epilepsy surgery centers. Study follow-up was completed on September 23, 2016, and data were analyzed from September 24, 2016, through April 24, 2018. Exposures:Standard anterior temporal lobe resection. Main Outcomes and Measures:Long-term postoperative seizure freedom. Results:In total, 107 patients with unilateral TLE (left-sided in 68; 63.6% women; median age, 37 years [interquartile range {IQR}, 30-45 years]) were included in the derivation cohort. Reduced postsurgical gray matter volumes were found in the ipsilateral piriform cortex in the postoperative seizure-free group (n = 46) compared with the non-seizure-free group (n = 61). A larger proportion of the piriform cortex was resected in the seizure-free compared with the non-seizure-free groups (median, 83% [IQR, 64%-91%] vs 52% [IQR, 32%-70%]; P < .001). The results were seen in left- and right-sided TLE and after adjusting for clinical variables, presurgical gray matter alterations, presurgical hippocampal volumes, and the proportion of white matter tract disconnection. Findings were externally validated in 2 independent cohorts (31 patients; left-sided TLE in 14; 54.8% women; median age, 41 years [IQR, 31-46 years]). The resected proportion of the piriform cortex was individually associated with seizure outcome after surgery (derivation cohort area under the curve, 0.80 [P < .001]; external validation cohorts area under the curve, 0.89 [P < .001]). Removal of at least half of the piriform cortex increased the odds of becoming seizure free by a factor of 16 (95% CI, 5-47; P < .001). Other mesiotemporal structures (ie, hippocampus, amygdala, and entorhinal cortex) and the overall resection volume were not associated with outcomes. Conclusions and Relevance:These results support the importance of resecting the piriform cortex in neurosurgical treatment of TLE and suggest that this area has a key role in seizure generation.

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