- Email: [email protected]
Quality of life after surgery for temporal lobe epilepsy: A 5-year follow-up
Epilepsy & Behavior 17 (2010) 506–510
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Quality of life after surgery for temporal lobe epilepsy: A 5-year follow-up Inês Cunha a,*, Jorge Oliveira b a b
Centro Hospitalar Psiquiátrico de Lisboa and Centro Hospitalar Lisboa Ocidental–Egas Moniz Hospital, Lisbon, Portugal Faculty of Psychology, University Lusófona, Lisbon, Portugal
a r t i c l e
i n f o
Article history: Received 24 October 2009 Revised 13 December 2009 Accepted 19 December 2009 Available online 3 March 2010 Keywords: Temporal lobe epilepsy surgery Quality of life QOL-31 questionnaire
a b s t r a c t The authors carried out a 5-year prospective study about the effects epilepsy surgery can have on a patient’s quality of life (QOL). They looked for the relationship between improvement on QOL after surgery and reduction of seizure frequency, seizure focus, age at surgery and previous psychopathology. They concluded that improvement in overall, cognitive and social function scores were statistically significant throughout the study. Seizure worry score ceased to be significant at the fifth year. Previous psychopathology was a negative influence on social and seizure worry score. Compared to left lobectomies, right lobectomies showed significant better results in overall scores at six months and one year followup. At 1 month follow-up, cognitive function was also significantly better in right lobectomies. Engels class I patients demonstrated statistically better results in the fourth and fifth years of follow-up. Neither years of disease nor patient age at surgery seemed to influence QOL. Ó 2009 Elsevier Inc. All rights reserved.
1. Introduction
2. Methodology
An epilepsy surgery program should have as its goal not only control of seizures, but also improvement in other domains of life. Enhancement of social, occupational, and independent functioning is an aim patients have in mind when they agree to surgery for the treatment of their epilepsy [1]. The literature is almost unanimous in associating improvement in quality of life with the success of surgery in controlling seizures of temporal lobe origin (Engel class I) [2–9]. Positive changes in quality of life tend to take as long as 2 years to consolidate [10– 12], and postoperative adjustment disorders during the first months after surgery have been described and need to be dealt with [12,13]. Moreover, good outcome with respect to quality of life has been associated with early surgical intervention [2], with preoperative quality of life [14], and with the neuropathology of mesial temporal sclerosis [15]. On the contrary, bad outcome has been associated with epilepsies caused by tumors and with both pre- and postsurgery psychopathology [6,12,16–20]. Correlations between laterality of focus and quality of life outcome have also been described, although studies have found associations both between right temporal lobectomy and poor quality of life [9,19,21] and between left temporal lobectomy and worsening quality of life [22]. The purpose of this study was to evaluate, in a prospective form, quality of life in a sample of patients submitted to temporal lobectomy.
We studied a sample of 32 patients consecutively referred for epilepsy surgery because of complex partial seizures of temporal lobe origin. Neurological diagnosis was established by scalp EEG, video/ EEG monitoring, MRI, and neuropsychological assessment. When needed, depth electrode EEGs and/or PET scans were obtained. Seizure frequency was based on patient diaries. Psychiatric evaluation of these patients was performed by the same psychiatrist before surgery; 1, 3, and 6 months after surgery; and annually for 5 years, using a semistructured clinical psychiatric interview, as well as the Symptom Checklist-90 (SCL-90) and Quality of Life in Epilepsy-31 (QOLIE-31) questionnaires [23]. Prior to surgery, according to DSM-IV classification, six patients were diagnosed as having dysthymia, three panic disorder, one generalized anxiety disorder, one delusional disorder, and one a previous adjustment depressive disorder. 2.1. Statistical analysis Data were submitted to repeated-measures ANOVA to evaluate quality of life (QOL) scores during the nine different assessments (i.e., presurgery, 1, 3, and 6 months postsurgery, and yearly until fifth year of follow-up) and the effects of the between-subject variables on QOL assessments. 3. Results
* Corresponding author. Address: Centro Hospitalar Psiquiátrico de Lisboa. Av. Brasil n° 53, 1749-002 Lisboa, Portugal. E-mail address: [email protected] (I. Cunha). 1525-5050/$ - see front matter Ó 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2009.12.012
Mean age was 41.4 years (SD = 9.5). Eleven patients were male and 21 were female. Sixty-three percent were married, and 48%
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
had achieved a ninth grade education. Thirty-two percent were nonspecialized workers, and 27% specialized workers [24]. Eighteen patients remained seizure free after 5 years of followup (Engel class IA) and 2 had only one seizure during the follow-up (Engel class IB). Because of the small sample size, these 20 patients were classified together as Engel class I. Overall QOL showed a steady increase after surgery until the second year of follow-up (F[8,14] = 2.699, P < 0.05). More specifically, post hoc tests revealed that presurgical evaluation differed significantly from other assessments (P < 0.05). Considering postsurgical outcome from the third to the fifth year of follow-up, these positive changes did not remain as steady as before, although they continued to be significantly higher than before surgery (Fig. 1). After surgery, seizure-related worry decreased significantly (F[8,14] = 2.588, P < 0.05), although it increased nonsignificantly around the fifth year (Fig. 2). With respect to cognitive function, patients showed a marked improvement from the presurgical level (F[8,14] = 2.316,
507
P < 0.05). Post hoc analyses revealed that the most marked difference occurred between the presurgical follow-up and the 3-month postsurgical evaluation (P < 0.01) (Fig. 3). Enhancement of social function was evident 6 months after surgery. Beyond this point, improvement in social function was more gradual, although social skills always stood clearly above the presurgical level (F[8,14] = 6.101, P < 0.001) (Fig. 4). This study did not show any significant differences in the QOLIE subscales Emotional Well-Being, Energy–Fatigue, and Medication Effects before and during the follow-up after surgery (see Appendix: Supplementary Data). As described earlier, some patients had psychopathology before they entered the epilepsy surgery program. Previous psychopathology was found to have a statistically significant effect on both Social Function (F[8, 14] = 3.672, P < 0.01) (Fig. 5) and Seizure Worry (F[8, 14] = 2.657, P < 0.05) scores (Fig. 6) during the 5-year follow-up. To explore these results further, estimated marginal means were tested with Bonferroni adjustment for presurgical versus
Fig. 1. Overall quality of life assessment. Error bars represent SE. Higher overall scores reflect better quality of life.
Fig. 2. Seizure-related worry assessment. Higher seizure worry scores represent less impact of seizures on quality of life.
508
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
Fig. 3. Cognitive function assessment. Higher cognitive function scores reveal higher cognitive functioning.
Fig. 4. Social function assessment. Higher social function scores reflect higher social functioning.
Fig. 5. Effect of previous psychopathology on social function scores. Higher social function scores reflect higher social functioning.
postsurgical social function score at the various postsurgical follow-up points. Pairwise comparisons showed significant differences between the presurgical evaluation and all (P < 0.05) but
Fig. 6. Effect of previous psychopathology on seizure worry scores. Higher seizure worry scores represent less impact of seizures on quality of life.
the 1-month postsurgical follow-up assessment (p > 0.05). Social Function score previous psychopathology interaction effects
509
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
were assessed with pairwise comparisons with Bonferroni adjustment. Differences between the two independent groups were found at 3 months (P < 0.05), 4 years (P < 0.05), and 5 years (P < 0.01) after surgery. With respect to the Seizure Worry subscale, pairwise comparisons revealed significant differences between the presurgical evaluation and all (P < 0.05) but the 1-month follow-up assessment (P > 0.05). Seizure worry previous psychopathology interaction effects significantly differed at 3 years (P < 0.05) and 4 years (P < 0.05) after surgery. Patients with a right temporal focus had significantly better outcomes than those with a left temporal focus in terms of both overall score (F[8,14] = 4.900, P < 0.05) and cognitive performance (F[8,14] = 9.258, P < 0.01). The same procedure was used to analyze differences between presurgical status and postsurgical outcome. Pairwise comparisons revealed significant differences between the presurgical evaluation and the postsurgical follow-up assessments at 3 months, 6 months, and 1, 2, and 4 years (P < 0.05), but not those at 1 month, 3 years, and 5 years (P > 0.05). To test whether left or right focus had an effect on overall score across assessments, pairwise comparisons with Bonferroni adjustment were carried out. With respect to overall score, the results indicated significant differences between patients with a left and those with a right temporal focus at 6 months (P < 0.05) and 1 year (P < 0.05) after surgery. With respect to cognitive function, there were significant differences between the presurgical evaluation and all (P < 0.05) but the 3-year (P > 0.05) postsurgical assessment. Pairwise comparisons between factors revealed significant differences only at the 1-month follow-up. Beyond this period, these differences ceased to be significant (Figs 7 and 8, respectively). No effects were found between years with disease at surgery or age at surgery and quality of life achieved postsurgery. There was a clear reduction in the number of seizures after surgery (t[27] = 3.903, P < 0.001), enabling reductions in antiepileptic medications (Table 1). If we separate patients who became seizure free (Engel class I) from those who continued to have seizures, independent of frequency (Engel classes II–IV), there was significant enhancement of QOL for Engel class I patients (F(8,14) = 4.785, P < 0.05) during the 5 years of follow-up (Fig. 9). Pairwise comparisons revealed significant differences between presurgical and other assessments (P < 0.05). Differences between patients who became seizure free and those who continued to have seizures were assessed with pairwise comparisons with Bonferroni adjustment. Statistically significant differences were observed 4
Fig. 8. Effect of lesion laterality on cognitive performance. Higher cognitive function scores reveal higher cognitive functioning.
Table 1 Effects of surgery on seizure frequency.
Before surgery After surgery
n
Mean (SD) number of seizures
18 10
8.53 (11.65) 0.43 (0.89) t = 3.903, P < 0.001
Fig. 9. Effect of seizures on overall score. Higher overall scores reflect better quality of life.
years (P < 0.05) and 5 years (P < 0.05) after surgery, suggesting better QOL for patients who became seizure free. Because of the small number of patients who had tumors in this sample (four cases), it was not possible to study the differences in quality of life between patients with mesial temporal sclerosis and those with alien tissue neuropathology. 4. Discussion
Fig. 7. Effect of lesion laterality on overall score. Higher overall scores reflect better quality of life.
In conclusion, our patients experienced quality of life, particularly in relation to seizure-related worry, overall quality-of-life, and cognitive and social function. We did not find any differences from the presurgical level with respect to medication effects, emotional well-being, and energy-fatigue levels. In the majority of related studies, improvement of quality of life depends on total control of seizures. In this study, patients as a whole had a significant improvement in their quality of life after surgery, even if they did not achieve total control of seizures. Nevertheless, those who became seizure free showed even more positive differences in quality of life in comparison with patients in
510
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
Engel classes II–IV (Fig. 9). These findings indicate that it is not necessary to become seizure free to obtain better quality of life after surgery, although this gain is more significant for Engel class I patients. Even for patients for whom surgery is not expected to achieve total control of seizures, the benefits on quality of life should be taken into account when deciding on surgery. Cognitive function was better in patients who underwent right temporal lobectomy than in those who underwent left temporal lobectomy. These findings are consistent with the fact that verbal memory is sustained by proper functioning of the left hippocampus. Overall quality-of-life scores were also better for those who underwent right temporal lobe surgery. The same results were obtained by Andelman et al. [22], although findings regarding differences in quality of life according to focus lateralization differ widely. Patients without presurgical psychopathology had better quality of life than patients who had a psychiatric diagnosis before surgery. The same conclusion is found in several studies [6,9,18], making better psychiatric evaluation and follow-up of fundamental importance. This finding draws attention to the need for epilepsy surgery programs to include a standard psychiatric interview in routine presurgical evaluations. Improvement in quality of life was not correlated with age at epilepsy onset nor age at time of surgery. Those findings differ from the results of other studies that indicate better quality of life for patients with epilepsies of shorter duration [3] or for patients undergoing surgery earlier in life [2,3]. Comparison of studies on quality of life after epilepsy surgery reveals a variety of results. This can be the consequence of differences in characteristics and sizes of samples and in methodology, but it also indicates that quality of life is not a linear concept, nor simply the end result of several factors put together. Such factors as previous personality, quality of life, financial status, education, and IQ may, undoubtedly, interfere with the results and have not been completely studied. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.yebeh.2009.12.012. References [1] Taylor DC, McMackin D, Saunton H, Delanty N, Phillips J. Patients’ aims for epilepsy surgery: desires beyond seizure freedom. Epilepsia 2001;42:629–33.
[2] Mihara T, Inoue Y, Matsuda, et al. Recommendation of early surgery from the viewpoint of daily quality of life. Epilepsia 1996;37(Suppl. 3):33–6. [3] Kellett MW, Smith DF, Chadwick DW. Quality of life after surgery of epilepsy. J Neurol Neurosurg Psychiatry 1997;63:52–8. [4] Birbeck GL, Hays RD, Cui X, Vickrey BG. Seizure reduction and quality of life improvements in people with epilepsy. Epilepsia 2002;43:535–8. [5] Lowe AJ, David E, Kilpatrick CJ, et al. Epilepsy surgery for pathologically proven hippocampal sclerosis provides long-term seizure control and improved quality of life. Epilepsia 2004;45:237–42. [6] Aydemir N, Ozkara C, Canbeyli R, Tekcan A. Changes in quality of life and selfperspective related to surgery in patients with temporal lobe epilepsy. Epilepsy Behav 2004;5:735–42. [7] Langfitt JT, Westerveld M, Hamberger MJ, et al. Worsening of quality of life after epilepsy surgery: effect of seizures and memory decline. Neurology 2007;68:88–94. [8] Tanriverdi T, Poulin N, Olivier A. Life 12 years after temporal lobe epilepsy surgery: a long-term, prospective clinical study. Seizure 2008;17:339–49. [9] Engel Jr J. Surgical treatment of epilepsies. 2nd ed. New York: Raven Press; 1993. [10] McLachlan RS, Rose KJ, Derry PA, Bonnar C, Blume WT, Girvin JP. Healthrelated quality of life and seizure control in temporal lobe epilepsy. Ann Neurol 1997;41:482–9. [11] Spencer SS, Berg AT, Vickrey BG, et al. Health-related quality of life over time since respective epilepsy surgery. Ann Neurol 2007;62:327–34. [12] Wilson SJ, Bladin PF, Saling MM, Pattison PE. Characterizing psychological outcome trajectories following seizure surgery. Epilepsy Behav 2005;6:570–80. [13] Wilson SJ, Bladin MM, McIntosh AM, Lawrence JA. The longitudinal course of adjustment after seizure surgery. Seizure 2001;10:165–72. [14] Rose HJ, Derry PA, Wiebe S, McLachlan RS. Determinants of health-related quality of life after temporal lobe epilepsy surgery. Qual Life Res 1996;5:392–402. [15] Trimble MR. Behavioral changes following temporal lobetomy, with special reference to psychosis. J Neurol Neurosurg Psychiatry 1992;55:89–91. [16] Whitman S, Hermann BP, Gordon AC. Psychopathology in epilepsy: how great is the risk? Biol Psychiatry 1984;19:213–36. [17] Kanner AM, Tilwalli S, Byrne R. Psychiatric and neurologic predictors of postsurgical complications following a temporal lobectomy. Neurology 2005;64(Suppl. 1):A358. [18] Loring DW, Meador KJ, Lee GP. Determinants of quality of life in epilepsy. Epilepsy Behav 2004;5:976–80. [19] Nees H, Moriarty J, Kitchen D, Trimble M. Psychosocial and neurobehavioral factors related to surgical treatment for partial epilepsy: a multivariate analysis. Epilepsy Behav 2001;2:135–9. [20] Bladin PF. Pychosocial difficulties and outcome after temporal lobectomy. Epilepsia 1992;33:898–907. [21] Naylor AS, Rogvi-Hansen B, Kessing L, Kruse-Larsen C. Psychiatric morbidity after surgery for epilepsy: short term follow-up of patients undergoing amygdalohippocampectomy. J Neurol Neurosurg Psychiatry 1994;57:1375–81. [22] Andelman F, Fried I, Neufeld MY. Quality of life self-assessment as a function of lateralization of lesion in candidates for epilepsy surgery. Epilepsia 2001;42:549–55. [23] Cramer A, Perrine K, Devinsky O, Bryant-Comstock L, Meador K, Hermann B. Development and cross-cultural translations of a 31-item quality of life in epilepsy inventory. Epilepsia 1998;39:81–8. [24] Classificação Nacional de Profissões. Instituto de Emprego e Formação Profissional. 2nd ed. Elo- Publicidade, Artes Gráficas Lda; 2001.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Quality of life after surgery for temporal lobe epilepsy: A 5-year follow-up Inês Cunha a,*, Jorge Oliveira b a b
Centro Hospitalar Psiquiátrico de Lisboa and Centro Hospitalar Lisboa Ocidental–Egas Moniz Hospital, Lisbon, Portugal Faculty of Psychology, University Lusófona, Lisbon, Portugal
a r t i c l e
i n f o
Article history: Received 24 October 2009 Revised 13 December 2009 Accepted 19 December 2009 Available online 3 March 2010 Keywords: Temporal lobe epilepsy surgery Quality of life QOL-31 questionnaire
a b s t r a c t The authors carried out a 5-year prospective study about the effects epilepsy surgery can have on a patient’s quality of life (QOL). They looked for the relationship between improvement on QOL after surgery and reduction of seizure frequency, seizure focus, age at surgery and previous psychopathology. They concluded that improvement in overall, cognitive and social function scores were statistically significant throughout the study. Seizure worry score ceased to be significant at the fifth year. Previous psychopathology was a negative influence on social and seizure worry score. Compared to left lobectomies, right lobectomies showed significant better results in overall scores at six months and one year followup. At 1 month follow-up, cognitive function was also significantly better in right lobectomies. Engels class I patients demonstrated statistically better results in the fourth and fifth years of follow-up. Neither years of disease nor patient age at surgery seemed to influence QOL. Ó 2009 Elsevier Inc. All rights reserved.
1. Introduction
2. Methodology
An epilepsy surgery program should have as its goal not only control of seizures, but also improvement in other domains of life. Enhancement of social, occupational, and independent functioning is an aim patients have in mind when they agree to surgery for the treatment of their epilepsy [1]. The literature is almost unanimous in associating improvement in quality of life with the success of surgery in controlling seizures of temporal lobe origin (Engel class I) [2–9]. Positive changes in quality of life tend to take as long as 2 years to consolidate [10– 12], and postoperative adjustment disorders during the first months after surgery have been described and need to be dealt with [12,13]. Moreover, good outcome with respect to quality of life has been associated with early surgical intervention [2], with preoperative quality of life [14], and with the neuropathology of mesial temporal sclerosis [15]. On the contrary, bad outcome has been associated with epilepsies caused by tumors and with both pre- and postsurgery psychopathology [6,12,16–20]. Correlations between laterality of focus and quality of life outcome have also been described, although studies have found associations both between right temporal lobectomy and poor quality of life [9,19,21] and between left temporal lobectomy and worsening quality of life [22]. The purpose of this study was to evaluate, in a prospective form, quality of life in a sample of patients submitted to temporal lobectomy.
We studied a sample of 32 patients consecutively referred for epilepsy surgery because of complex partial seizures of temporal lobe origin. Neurological diagnosis was established by scalp EEG, video/ EEG monitoring, MRI, and neuropsychological assessment. When needed, depth electrode EEGs and/or PET scans were obtained. Seizure frequency was based on patient diaries. Psychiatric evaluation of these patients was performed by the same psychiatrist before surgery; 1, 3, and 6 months after surgery; and annually for 5 years, using a semistructured clinical psychiatric interview, as well as the Symptom Checklist-90 (SCL-90) and Quality of Life in Epilepsy-31 (QOLIE-31) questionnaires [23]. Prior to surgery, according to DSM-IV classification, six patients were diagnosed as having dysthymia, three panic disorder, one generalized anxiety disorder, one delusional disorder, and one a previous adjustment depressive disorder. 2.1. Statistical analysis Data were submitted to repeated-measures ANOVA to evaluate quality of life (QOL) scores during the nine different assessments (i.e., presurgery, 1, 3, and 6 months postsurgery, and yearly until fifth year of follow-up) and the effects of the between-subject variables on QOL assessments. 3. Results
* Corresponding author. Address: Centro Hospitalar Psiquiátrico de Lisboa. Av. Brasil n° 53, 1749-002 Lisboa, Portugal. E-mail address: [email protected] (I. Cunha). 1525-5050/$ - see front matter Ó 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2009.12.012
Mean age was 41.4 years (SD = 9.5). Eleven patients were male and 21 were female. Sixty-three percent were married, and 48%
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
had achieved a ninth grade education. Thirty-two percent were nonspecialized workers, and 27% specialized workers [24]. Eighteen patients remained seizure free after 5 years of followup (Engel class IA) and 2 had only one seizure during the follow-up (Engel class IB). Because of the small sample size, these 20 patients were classified together as Engel class I. Overall QOL showed a steady increase after surgery until the second year of follow-up (F[8,14] = 2.699, P < 0.05). More specifically, post hoc tests revealed that presurgical evaluation differed significantly from other assessments (P < 0.05). Considering postsurgical outcome from the third to the fifth year of follow-up, these positive changes did not remain as steady as before, although they continued to be significantly higher than before surgery (Fig. 1). After surgery, seizure-related worry decreased significantly (F[8,14] = 2.588, P < 0.05), although it increased nonsignificantly around the fifth year (Fig. 2). With respect to cognitive function, patients showed a marked improvement from the presurgical level (F[8,14] = 2.316,
507
P < 0.05). Post hoc analyses revealed that the most marked difference occurred between the presurgical follow-up and the 3-month postsurgical evaluation (P < 0.01) (Fig. 3). Enhancement of social function was evident 6 months after surgery. Beyond this point, improvement in social function was more gradual, although social skills always stood clearly above the presurgical level (F[8,14] = 6.101, P < 0.001) (Fig. 4). This study did not show any significant differences in the QOLIE subscales Emotional Well-Being, Energy–Fatigue, and Medication Effects before and during the follow-up after surgery (see Appendix: Supplementary Data). As described earlier, some patients had psychopathology before they entered the epilepsy surgery program. Previous psychopathology was found to have a statistically significant effect on both Social Function (F[8, 14] = 3.672, P < 0.01) (Fig. 5) and Seizure Worry (F[8, 14] = 2.657, P < 0.05) scores (Fig. 6) during the 5-year follow-up. To explore these results further, estimated marginal means were tested with Bonferroni adjustment for presurgical versus
Fig. 1. Overall quality of life assessment. Error bars represent SE. Higher overall scores reflect better quality of life.
Fig. 2. Seizure-related worry assessment. Higher seizure worry scores represent less impact of seizures on quality of life.
508
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
Fig. 3. Cognitive function assessment. Higher cognitive function scores reveal higher cognitive functioning.
Fig. 4. Social function assessment. Higher social function scores reflect higher social functioning.
Fig. 5. Effect of previous psychopathology on social function scores. Higher social function scores reflect higher social functioning.
postsurgical social function score at the various postsurgical follow-up points. Pairwise comparisons showed significant differences between the presurgical evaluation and all (P < 0.05) but
Fig. 6. Effect of previous psychopathology on seizure worry scores. Higher seizure worry scores represent less impact of seizures on quality of life.
the 1-month postsurgical follow-up assessment (p > 0.05). Social Function score previous psychopathology interaction effects
509
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
were assessed with pairwise comparisons with Bonferroni adjustment. Differences between the two independent groups were found at 3 months (P < 0.05), 4 years (P < 0.05), and 5 years (P < 0.01) after surgery. With respect to the Seizure Worry subscale, pairwise comparisons revealed significant differences between the presurgical evaluation and all (P < 0.05) but the 1-month follow-up assessment (P > 0.05). Seizure worry previous psychopathology interaction effects significantly differed at 3 years (P < 0.05) and 4 years (P < 0.05) after surgery. Patients with a right temporal focus had significantly better outcomes than those with a left temporal focus in terms of both overall score (F[8,14] = 4.900, P < 0.05) and cognitive performance (F[8,14] = 9.258, P < 0.01). The same procedure was used to analyze differences between presurgical status and postsurgical outcome. Pairwise comparisons revealed significant differences between the presurgical evaluation and the postsurgical follow-up assessments at 3 months, 6 months, and 1, 2, and 4 years (P < 0.05), but not those at 1 month, 3 years, and 5 years (P > 0.05). To test whether left or right focus had an effect on overall score across assessments, pairwise comparisons with Bonferroni adjustment were carried out. With respect to overall score, the results indicated significant differences between patients with a left and those with a right temporal focus at 6 months (P < 0.05) and 1 year (P < 0.05) after surgery. With respect to cognitive function, there were significant differences between the presurgical evaluation and all (P < 0.05) but the 3-year (P > 0.05) postsurgical assessment. Pairwise comparisons between factors revealed significant differences only at the 1-month follow-up. Beyond this period, these differences ceased to be significant (Figs 7 and 8, respectively). No effects were found between years with disease at surgery or age at surgery and quality of life achieved postsurgery. There was a clear reduction in the number of seizures after surgery (t[27] = 3.903, P < 0.001), enabling reductions in antiepileptic medications (Table 1). If we separate patients who became seizure free (Engel class I) from those who continued to have seizures, independent of frequency (Engel classes II–IV), there was significant enhancement of QOL for Engel class I patients (F(8,14) = 4.785, P < 0.05) during the 5 years of follow-up (Fig. 9). Pairwise comparisons revealed significant differences between presurgical and other assessments (P < 0.05). Differences between patients who became seizure free and those who continued to have seizures were assessed with pairwise comparisons with Bonferroni adjustment. Statistically significant differences were observed 4
Fig. 8. Effect of lesion laterality on cognitive performance. Higher cognitive function scores reveal higher cognitive functioning.
Table 1 Effects of surgery on seizure frequency.
Before surgery After surgery
n
Mean (SD) number of seizures
18 10
8.53 (11.65) 0.43 (0.89) t = 3.903, P < 0.001
Fig. 9. Effect of seizures on overall score. Higher overall scores reflect better quality of life.
years (P < 0.05) and 5 years (P < 0.05) after surgery, suggesting better QOL for patients who became seizure free. Because of the small number of patients who had tumors in this sample (four cases), it was not possible to study the differences in quality of life between patients with mesial temporal sclerosis and those with alien tissue neuropathology. 4. Discussion
Fig. 7. Effect of lesion laterality on overall score. Higher overall scores reflect better quality of life.
In conclusion, our patients experienced quality of life, particularly in relation to seizure-related worry, overall quality-of-life, and cognitive and social function. We did not find any differences from the presurgical level with respect to medication effects, emotional well-being, and energy-fatigue levels. In the majority of related studies, improvement of quality of life depends on total control of seizures. In this study, patients as a whole had a significant improvement in their quality of life after surgery, even if they did not achieve total control of seizures. Nevertheless, those who became seizure free showed even more positive differences in quality of life in comparison with patients in
510
I. Cunha, J. Oliveira / Epilepsy & Behavior 17 (2010) 506–510
Engel classes II–IV (Fig. 9). These findings indicate that it is not necessary to become seizure free to obtain better quality of life after surgery, although this gain is more significant for Engel class I patients. Even for patients for whom surgery is not expected to achieve total control of seizures, the benefits on quality of life should be taken into account when deciding on surgery. Cognitive function was better in patients who underwent right temporal lobectomy than in those who underwent left temporal lobectomy. These findings are consistent with the fact that verbal memory is sustained by proper functioning of the left hippocampus. Overall quality-of-life scores were also better for those who underwent right temporal lobe surgery. The same results were obtained by Andelman et al. [22], although findings regarding differences in quality of life according to focus lateralization differ widely. Patients without presurgical psychopathology had better quality of life than patients who had a psychiatric diagnosis before surgery. The same conclusion is found in several studies [6,9,18], making better psychiatric evaluation and follow-up of fundamental importance. This finding draws attention to the need for epilepsy surgery programs to include a standard psychiatric interview in routine presurgical evaluations. Improvement in quality of life was not correlated with age at epilepsy onset nor age at time of surgery. Those findings differ from the results of other studies that indicate better quality of life for patients with epilepsies of shorter duration [3] or for patients undergoing surgery earlier in life [2,3]. Comparison of studies on quality of life after epilepsy surgery reveals a variety of results. This can be the consequence of differences in characteristics and sizes of samples and in methodology, but it also indicates that quality of life is not a linear concept, nor simply the end result of several factors put together. Such factors as previous personality, quality of life, financial status, education, and IQ may, undoubtedly, interfere with the results and have not been completely studied. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.yebeh.2009.12.012. References [1] Taylor DC, McMackin D, Saunton H, Delanty N, Phillips J. Patients’ aims for epilepsy surgery: desires beyond seizure freedom. Epilepsia 2001;42:629–33.
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