Abstracts

Elective surgical intervention for older (over 50 years) patients with medically intractable epilepsy is rarely undertaken, even in institutions with extensive experience. This likely reflects biases among patients, physicians and epileptologists. Furthermore, the observation that epilepsy duration and older age are predictors of adverse long-term surgical outcome argues against surgical intervention in the older patients. We retrospectively reviewed the outcomes in older patients where surgery was undertaken solely on the grounds of intractability of partial epilepsy. We performed a retrospective analysis of patients operated on at a single institution over a 16-year period (1998-2005). All cases were age 50 years or older. All cases underwent epilepsy surgery solely on the grounds of disabling, medically intractable partial epilepsy. Where data was not available from chart review, patients were contacted directly. Surgical outcome was defined using Engel[apos]s classification. Thirteen of the 244 patients who received a surgical procedure for intractable partial epilepsy at the MGH during a 16-year period were 50 years of age or older. All patients had disabling partial seizures that were refractory to antiepileptic drug medication. One patient had a post-operative wound infection. No other adverse neurosurgical complications occurred. The female:male ratio was 9:4. The mean age at time of surgery was 53.7 years (range 50-59). The majority of patients had epilepsy for more than 20 years, though four patients had seizures for less than 10 years duration. Nine patients had a standard anterior temporal lobectomy while the remainder had frontal lobe resections. Postoperative seizure outcome was Engel class I in 9 (59%), II in 4 (31%), III in 1 (7.6%), and IV in 0 (0%) patients. One patient died three years after surgery for unrelated reasons. The mean follow-up time was 35 months (range 12 mo [ndash] 11 years). Neuropathological evaluation confirmed hippocampal sclerosis in 6 cases, non-specific changes in 2 cases, post-traumatic encephalomalacia/gliosis in 3 cases, benign glial cyst in 1 case and a cavernoma in 1 case. In patients aged 50 years and older, the mean age of onset of partial seizures ranged from infancy to 54. Six of the seven patients with a class 1 outcome had epilepsy for greater than twenty years duration (mean 42 years duration). Twelve of thirteen patients had a favorable seizure outcome, and seven patients are currently seizure free. The pre-operative duration of epilepsy did not negatively impact on seizure outcome. Biases in the selection of older patients for surgical intervention may limit the utilization of epilepsy surgery but may ensure careful selective of appropriate candidates. Epilepsy surgery is a plausible and potentially curative intervention in carefully selected older patients with medically refractory epilepsy.