Epilepsia, 47(5):928–933, 2006 Blackwell Publishing, Inc. C 2006 International League Against Epilepsy
Normalization of Quality of Life Three Years after Temporal Lobectomy: A Controlled Study ∗ †‡Mohamad A. Mikati, ‡§Youssef G. Comair, and ∗ ‡Amal Rahi ∗ Department of Pediatrics, †Department of Internal Medicine, Division of Neurology, ‡Adult and Pediatric Epilepsy Program, and §Department of Surgery, Division of Neurosurgery, American University of Beirut Medical Center, Beirut, Lebanon
Summary: Purpose: The goal of epilepsy surgery is not merely to control previously intractable seizures, but also to improve quality of life (QOL). Our goals were to assess, in our Middle Eastern population, the QOL of adults with temporal lobe epilepsy (TLE) 3 years after temporal lobectomy as compared with matched TLE patients who did not undergo surgery and with healthy individuals in the same community. Methods: Twenty consecutive TLE patients who underwent temporal lobectomy 3 years previously were matched in the following variables: age, sex, seizure frequency, seizure duration, age at onset of epilepsy, duration of epilepsy, and number of medications, with 17 TLE patients who underwent the presurgical evaluation and subsequent optimization of medical therapy but did not undergo surgery. They were also matched for age, sex, educational level, income, and residence with 20 healthy
individuals. All groups were interviewed by using the ESI-55 questionnaire. Results: Compared with the nonsurgery group, QOL was significantly better in the surgery group (85% seizure free) in the well-being, functioning, and role-limitation domains. QOL was similar in the surgery and healthy control groups in all domains and scales. The nonsurgery group scored significantly lower than healthy controls in the functioning and role-limitation domains. Conclusions: Intractable TLE was associated with marked impairments in QOL despite continued attempts to optimize medical therapy. Three years after temporal lobectomy QOL in our patient population achieved levels similar to those of matched healthy individuals. To our knowledge, this is the first study to report normalization of QOL after temporal lobectomy, in any population. Key Words: QOL—temporal lobe epilepsy— Lobectomy.
The first 2 years after epilepsy surgery are usually a time to recuperate from the surgery and to taper antiepileptic medications (AEDs). Thus major changes in quality of life (QOL) can be expected to occur in subsequent years as the patient takes advantage of his or her condition and adapts to it at home and at work (1–5). The real value of postsurgery QOL studies is, thus, eventually to identify changes in QOL that are sustained on a long-term basis after surgery and to determine whether QOL after epilepsy surgery is comparable to that of the normal “healthy” population. To our knowledge, only one study has compared QOL of epilepsy surgery patients with that of healthy individuals (6). In addition, adaptation after epilepsy surgery is likely to be population and culture dependent. The purpose of the present study was, thus, to investigate, in our Lebanese
Middle Eastern population, the QOL of patients that had undergone temporal lobectomy 3 years previously as compared with epilepsy nonsurgery patients and with healthy individuals. METHODS The study population consisted of three groups. The surgery group included the first 20 adult epilepsy patients who underwent temporal lobe epilepsy surgery in our center when seen at their 3-year follow up. The nonsurgery group included 17 temporal lobe epilepsy patients who underwent long-term monitoring (LTM) as part of their presurgical evaluation during the same period, but who were ineligible for surgery. The healthy controls group included 20 healthy subjects with no chronic diseases. In the nonsurgery group, surgery was not performed for one or both of the following reasons: inability to localize a single epileptic focus, or the focus was located in an eloquent area of the brain where cognitive or motor impairments such as memory or speech deficits could result if the focus was resected. The two comparison groups were matched with the surgery group for age, sex, place of residence, educational level, and income level. In addition, the two epilepsy
Accepted January 2, 2005. Address correspondence and reprint requests to Dr. M. Mikati at Adult and Pediatric Epilepsy Program, Department of Pediatrics, American University of Beirut, Beirut, Lebanon. E-mail:
[email protected]. Office address: Department of Pediatrics, 6th floor, American University of Beirut Medical Center, PO Box: 11-0236 Riad El Solh, 1107 2020, Beirut, Lebanon
928
QUALITY OF LIFE NORMALIZATION AND TEMPORAL LOBECTOMY groups were also matched for seizure frequency, seizure duration, age at onset of epilepsy, duration of epilepsy in the patient’s life, and number of medications. Data were collected through interviews with the patients according to a preset questionnaire containing questions on demographic and clinical characteristics and QOL. Demographic characteristics included age, sex, educational level, place of residence, occupation, income, marital status, and driving status. Clinical data included type and frequency of seizures, age at seizure onset, duration of seizures, time of surgery, number of current AEDs, comorbidity (including psychiatric conditions), and neurologic examination findings. QOL was assessed by using the ESI-55 questionnaire containing 55 items, the reliability and validity of which have been established by Vickrey et al. (7,8). This questionnaire was comprehensively translated into the Arabic language through a professional (sworn) translator to make sure that the translated version is accurate. Its reliability was then tested as part of a master’s thesis of an MPH student. The questionnaire was administered during the same period to all three groups to control for the potentially changing socioeconomic situation in the country. The 55 QOL items were divided into three domains: 1.
2.
3.
The “well being” domain included five scales: health perception (10 items), energy/fatigue (four items), emotional well-being (five items), pain (two items), and overall QOL (two items). The “functioning” domain included three scales: physical function (10 items), social functioning (two items), and cognitive function (five items). The “role-limitation” domain included three scales: role limitation due to physical (five items), emotional (five items), and memory problems (five items).
Demographic and clinical data were compared between the surgery, nonsurgery, and healthy control groups using the analysis of variance (ANOVA) test for continuous data and χ 2 test for categoric data. The LSD post hoc test was used to determine which groups differed significantly. When the surgery and the nonsurgery groups were compared with respect to their clinical characteristics, the t test was used for continuous data and the χ 2 test for categoric data. Each of the 55 items in the ESI-55 questionnaire generated a raw score. This was transformed into a linear score out of a maximum of 100. The transformed item scores were also added to generate a mean score for each of the 11 scales and an average total score for each of the three domains. The three study groups were compared by using the ANOVA test for the following scores: (a) each of the three domains and (b) each of the 11 scales. Data were entered and analyzed by using SPSS version 10 for Win-
929
dows software. Power analysis was performed by using the STATA software version 7. RESULTS The mean follow-up time for the surgery group (mean ± SD) was 33.85 ± 9.08 months after surgery, and for the nonsurgery group, 32.53 ± 12.52 months after the presurgical evaluation (p = 0.71). The study groups did not differ with respect to demographic and clinical characteristics at baseline (p > 0.05) (Table 1). The pathologies of the resected temporal lobes in our study patients included mesial temporal sclerosis (13 patients), benign temporal lobe tumors (six patients), and vascular malformation (one patient). On follow-up, 17 (85%) of the surgery group and six (35%) of the nonsurgery group were seizure free (p < 0.001). Only 15% of the surgery group were taking two or more AEDs as compared with 71% of the nonsurgery group (p = 0.002). Of those who underwent surgery, 17 (85%) had Engel class IA outcome (completely seizure free since surgery), two had Engel class IB (nondisabling simple partial seizures only since surgery), and one had Engel class II A (initially free of disabling seizures but has rare seizures now) (9). At the time of interview, four of the 20 surgical patients had intermittent and mild neurologic symptoms after surgery. These consisted of: mild lowerlimb pain, occasional arm tingling, mild word-finding difficulty, and mild difficulty in memorizing names. The surgery group scored significantly higher than the nonsurgery group on the “well-being” (p < 0.001), “functioning” (p = 0.04), and “role-limitation” (p = 0.01) domains. Differences were significant in three of the five “well-being” scales: the emotional well-being, pain, and overall QOL scales (p = 0.01, p < 0.001, and p = 0.02, respectively). In the “functioning” scales, the “physical functioning” and the “cognitive functioning” scores were significantly higher in the surgery group as compared with the nonsurgery group (p = 0.04 and p < 0.001, respectively). In the “role-limitation” scales, the “role limitation due to physical problems” and the “role limitation due to memory problems” scores were significantly higher in the surgery than in the nonsurgery group (p = 0.01 and p = 0.01, respectively) (Table 2). The surgery group did not differ significantly from the healthy control group in any domain or in any scale except one: the emotional well-being scale. During the interviews, these patients repeatedly expressed their high satisfaction with the outcome of their surgery and their enthusiasm about leading a more fulfilling life than was possible for them before the surgery. The three patients who did not have complete seizure control were satisfied with the results of their surgery, but they did not express the same enthusiasm as did those who were completely seizure free. Epilepsia, Vol. 47, No. 5, 2006
930
M. MIKATI ET AL. TABLE 1. Demographic and clinical characteristics of surgery patients, nonsurgery patients, and healthy controls Variable Age (on f/up)ab Sex (male)a Educational level (low)a Working status before surgery or presurgical evaluation (working) Working status after surgery or presurgical evaluation (working) Marital status before surgery or presurgical evaluation (married) Marital status after surgery or presurgical evaluation (married) Seizure frequency before surgery or presurgical evaluation/moab Seizure duration (in minutes)b Epilepsy duration (yr)ab Age at seizure onset (yr)ab Number of medications before surgery or presurgical evaluation (taking more than 2 AEDs) Presence of psychiatric comorbidity after surgery/presurgical evaluation
Surgery (n = 20)
Nonsurgery (n = 17)
Healthy (n = 20)
p Value
30.50 ± 9.8 10 5 10
31.47 ± 9.27 6 6 10
29.20 ± 8.51 10 2 12
0.75 0.59 0.36 0.79
12
10
13
0.92
3
4
5
0.71
5
8
7
0.37
13.13 ± 13.45
10.12 ± 8.29
—
0.43
2.25 ± 4.32 20.10 ± 10.03 9.30 ± 8.74 18
2.85 ± 3.97 16.50 ± 10.99 14.82 ± 8.01 13
— — — —
0.67 0.30 0.06 0.31
4
1
—
0.23
a Matched b Mean
variable. ± SD.
Power analysis revealed that at a power of 80% and p < 0.05, differences of 3–29% could have been detected (had they existed) between the healthy controls and epilepsy surgery group in each of the tested scales and domains. The nonsurgery group did worse than the healthy control group. The domain and scale scores that were significantly higher in healthy controls than in the epilepsy nonsurgery patients were the “functioning” domain, the “cognitive functioning” scale, the “role-limitation” do-
main, the “role limitation due to memory problems” scale, and the “pain” scale of the “well-being domain” (Table 2). DISCUSSION The current study shows that QOL was significantly better in TLE patients who underwent surgery 3 years previously than in those who did not. Moreover, QOL of the surgery patients was similar to that of healthy controls
TABLE 2. Scores of the ESI-55 “well-being,” “functioning,” and “role-limitation” domains with the corresponding scales for the surgery, nonsurgery patients, and healthy controls
Well-being domain Health-perception scale Energy and fatigue scale Emotional well-being scale Pain Overall QOL Functioning domain Physical-functioning scale Social-functioning scale Cognitive-functioning scale Role-limitation domain Role limitation due to physical problems scale Role limitation due to emotional problems scale Role limitation due to memory problems scale
LSD p Value Healthy vs. nonsurgery
LSD p Value Healthy vs. surgery
Surgery (mean ± SD)
Nonsurgery (mean ± SD)
Control (mean ± SD)
79.70 ± 12.50 83.78 ± 14.44 72.5 ± 20.49 74.60 ± 16.73 88.87 ± 14.52 79.25 ± 18.35 87.33 ± 14.11 98.50 ± 3.28 77.13 ± 29.74 86.37 ± 14.66 89.67 ± 15.37 96.00 ± 10.46
66.85 ± 12.10 74.80 ± 16.98 62.65 ± 22.22 59.29 ± 20.45 71.91 ± 20.47 66.03 ± 15.28 78.97 ± 16.04 93.52 ± 11.95 76.32 ± 29.44 67.06 ± 27.34 72.94 ± 29.29 75.29 ± 29.60
72.76 ± 12.10 85.19 ± 13.54 65.00 ± 24.44 62.40 ± 17.38 84.62 ± 15.00 71.00 ± 16.29 89.88 ± 5.65 96.00 ± 4.75 86.13 ± 14.47 87.54 ± 8.14 89.00 ± 11.30 83.00 ± 24.52
0.00 0.08 0.37 0.03 0.01 0.06 0.03 0.13 0.42 0.00 0.02 0.02
0.00 0.06 0.19 0.01 0.00 0.02 0.04 0.04 0.92 0.00 0.01 0.01
0.12 0.17 0.75 0.60 0.02 0.37 0.01 0.31 0.25 0.00 0.02 0.30
0.06 0.58 0.29 0.04 0.42 0.12 0.52 0.29 0.27 0.84 0.91 0.07
82.00 ± 32.38
72.94 ± 33.87
87.00 ± 19.76
0.34
0.35
0.15
0.59
91.00 ± 19.97
70.58 ± 37.49
97.00 ± 9.78
0.00
0.01
0.00
0.44
Bold indicates p < 0.05 (statistically significant). Epilepsia, Vol. 47, No. 5, 2006
LSD p Value Surgery vs. nonsurgery
ANOVA p Value
QUALITY OF LIFE NORMALIZATION AND TEMPORAL LOBECTOMY
931
TABLE 3A. Comparison of QOL scores of epilepsy surgery and epilepsy nonsurgery groups from studies done in Western populations
QOL scale Health perception Emotional well-being Energy Pain Overall QOL Physical function Social function Cognitive function Role limitation (physical) Role limitation (emotional) Role limitation (memory) Demographic/Clinical data Sample size (N)c %Temporal lobectomyd Mean follow-up time (yr) Age at evaluation (yr)c Sex (% male)c % Seizure freec Age at seizure onset (yr)c Epilepsy duration through life (yr)c
USA (Vickrey) 1995
Canada (Wiebe) 1997
Canada (McLachlan) 1997
U.K. (O’Donoghue) 1998
U.S.A. (Gilliam) 1999a
U.S.A. (Markand) 2000
Canada (Wiebe) 2001
+ 0 0 + 0 0 + 0 + + 0
+ + + NA 0 0 0 0 0 0 0
+ 0 0 0 0 0 + 0 + 0 +
+ NA NA NA + NA + + + 0 +
+ + + 0 + + + + + + +
+ + 0 0 + 0 + + + 0 0
NA NA NA NA +b NA NA NA NA NA NA
202/46 90 5.8 32.8/31.7 48/50 30.3/5.7 11.9/12.0 NA
43/14 100 1 33.6/37.7 51/21 42/0 11.6/19.3 21.6/19.3
51/21 100 2 33.9/36.2 47/33 40/0 12.1/17.0 NA
105/287 NA 2.3 31.0/34.0 45/46 48/14 NA NA/22
125/71 100 >1 yr 31e /33 42/48 65/18 12.3/14 18.7/19
53/37 100 1 32.0/37.9 33/18 73.6/10.8 12.3/13.4 19.7/24.5
40/40 100 1 35.5/34.4§ 42.5/52.5 38/3 14.3/16.2 21.2/18.2
+, Surgery group improved significantly in the average score for that scale compared with nonsurgery group undergoing presurgical evaluation but not surgery; 0, no significant difference was found in the average score for that scale between the surgery group and the nonsurgery group undergoing presurgical evaluation but not surgery; NA, data not available. a Surgery group/group awaiting surgery. b Mean global score. c Surgery group/nonsurgery group. d Percentage of patients in the surgery group who underwent temporal lobectomy versus other epilepsy surgery. e Age of patients at their presurgical evaluation or at randomization but not at follow-up.
in all domains and scales of the ESI-55 instrument. TLE patients who did not undergo surgery scored significantly lower than healthy controls in the functioning and rolelimitation domains. To our knowledge, our study is the first that has reported achievement of normal QOL measures after temporal lobectomy. In the literature we only found a single study that compared QOL of epilepsy patients after surgery with that of healthy controls. In this study, QOL was assessed by using the Chinese version, validated in Hong Kong, of the World Health Organization QOL Measure. This study found poorer QOL scores in nine patients who underwent successful temporal lobectomy as compared with 157 healthy controls in physical and psychological domains (6). Our surgery group was not significantly different from the healthy controls group in any scale of the QOL questionnaire. Patients in this group, understandably, because of the recent positive change in their life, scored higher than did healthy controls in the emotional well-being scale (3,5,10). The difference in outcome between our and the Chinese study may be related to (a) different social-support systems in the two populations, (b) percentage of patients who became seizure free, or (c) duration of follow-up time after surgery, or a combination of these.
Our current study also revealed significantly better results for the epilepsy surgery group as compared with the nonsurgery group in all three domains of QOL. Previous studies in the region demonstrated that after temporal lobectomy, QOL, in some but not all scales, is better in epilepsy surgery patients than in patients awaiting epilepsy surgery or not eligible for surgery (10,11). Our study documented differences in all, rather than in some, of these domains. This also is probably secondary to multiple factors: (a) high percentage of seizure-free patients (85% as compared with 48% in one prior study, (b) population-related factors such as the social and family support systems in our patient population, and (c) the duration of follow-up, 2.9 years in our study as compared with 6 months in one of the other two studies. A short duration of follow-up may not allow enough time for adaptation to the new seizure-free situation (1–5). Several studies have been performed worldwide on long-term QOL changes after epilepsy surgery (followup ranging from 3 to 9 years) (2,12–15). However, of the comparative studies investigating QOL after epilepsy surgery as compared with the QOL of nonsurgery groups (3,4,14,17–19) or as compared with QOL before surgery (16,20), our current study, similar to the study by Kellett et al. (1997), has, to our knowledge, the second longest
Epilepsia, Vol. 47, No. 5, 2006
932
M. MIKATI ET AL. TABLE 3B. Comparison of QOL scores of epilepsy surgery and epilepsy nonsurgery groups from studies done in nonwestern populations
QOL scale Health perception Emotional well-being Energy Pain Overall QOL Physical function Social function Cognitive function Role limitation (physical) Role limitation (emotional) Role limitation (memory) Impact of epilepsy score Demographic/Clinical data Sample size (N) c %Temporal lobectomy d Mean follow-up time (mo) Age at evaluation (yr) c Sex (% male) c % Seizure free c Age at seizure onset (yr)c Epilepsy duration through life (yr) c
Turkey (Aydemir) 2004a
Lebanon (Mikati) 2004
Turkey (Cankurtaran) 2005b
Lebanon (Mikati) 2006
0 0 0 0 0 0 0 0 0 + 0 +
+ 0 + 0 + 0 0 + 0 0 0 NA
+ 0 0 0 0 0 0 0 0 0 0 NA
0 + 0 + + + 0 + + 0 + NA
21/20 100 27 27/24.8 43/45 48/NA 8/6.3 19.1/18.5
20/20 75 13 32.1/32.2 55/55 85/0 11.5/15.5 19.2/17.0
22/22 100 6 30 50/50 95.5 10.5 82% >10 yr
20/17/20 100 33.2 ± 10.6 30.5/31.5 50/35 85/35 9.3/14.8 20.1/16.5
+, Surgery group improved significantly in the average score for that scale compared with the nonsurgery group undergoing presurgical evaluation but not surgery; 0, no significant difference was found in the average score for that scale between the surgery group and the nonsurgery group undergoing presurgical evaluation but not surgery; NA, data not available. a Surgery group/group awaiting surgery. b Before–after comparison. c Surgery group/nonsurgery group. d % of patients in the surgery group who underwent temporal lobectomy versus other epilepsy surgery.
follow-up time. The mean time after surgery in our study was 2.9 years, and that in the study by Vickrey et al. (1995) was 5.8 years (2,14). Similar to these western studies that used a method similar to ours (comparing a surgery and nonsurgery group), our current study showed improvements comparable to theirs in the well-being (three of five scales), functioning (two of three scales), and role-limitation domains (two of three scales), 3 years after surgery. Role-limitation improvements are more evident in studies with longer follow-ups like ours. Each of Vickrey et al. (1995), McLachlan et al. (1997), and O’Donoghue et al. (1998) (with follow-up periods of 5.8, 2, and 2.3 years, respectively), reported that two of the three “role-limitation” scales were better in the surgical group (4,14,17). In the study by Gilliam et al. (16) patients were followed up for >1 year after surgery, and better scores were reported as compared with patients awaiting surgery in all role-limitation scales (16). However, the studies with 1-year follow-ups reported less remarkable differences in those scales (3,18,19). These observations emphasize, again, the importance of time to help patients adapt positively to their new situations. We observed that at 3 years, more pronounced improvements were found than was noted in our previous study Epilepsia, Vol. 47, No. 5, 2006
that investigated patients 1 year after surgery (5). These improvements were noted in physical and cognitive functioning (the functioning domain) as well as in role limitations due to physical problems and due to memory problems (in the role-limitation domain). Differences between our 1-year and the 3-year follow-up data are understandable because of the passage of time (1–5). In addition, our previous study included a few non-TLE patients (four of 20), whereas this study included only patients with TLE (5). In our current study, healthy controls scored better than our nonsurgery epilepsy patients in the functioning domain (especially cognitive functioning) and role-limitation domain (especially role limitation due to memory) but not in the well-being domain. Such results are similar to those found in other populations (21–24) and are probably related to multiple socioeconomic and other population-related factors. The favorable results seen after epilepsy surgery, in our and in all the cited studies, are possibly also related to reduction in AED therapy. AED polytherapy has been shown to result in memory loss, concern over medication long-term effects, difficulty in taking the medications, and
QUALITY OF LIFE NORMALIZATION AND TEMPORAL LOBECTOMY trouble with leisure-time activities, and overall state of health as compared with monotherapy patients (25). We would like to bring to attention some limitations of our method. 1.
2.
3.
Although the three groups we studied were rigorously matched, perfect matching is not possible in any study. Specifically, the two epilepsy groups did differ in the fact that one group qualified for epilepsy surgery and one did not. This could have acted as a confounding variable that could have affected our results. Overall QOL scores were high in many scales in both the surgery and the nonsurgery patients (ceiling effect). This could have resulted in insignificant differences between the two groups in these categories. The ESI-55 questionnaire is not necessarily an ideal instrument, and probably other aspects of QOL are relevant that this instrument is not measuring, especially in the healthy population.
These limitations notwithstanding, we still believe that our study has the following advantages: (a) we matched the surgical and the other two groups rigorously; (b) we grouped the ESI-55 scales into “well-being,” “functioning,” and “role limitation” domains allowing, in our opinion, an easier interpretation and analysis of the collected data; (c) patients were assessed through interviews, which added a qualitative aspect to the data; (d) our method of comparing surgical patients with matched nonsurgical patients has been previously used in other articles in the field (3,4,14,17–19), but our study is the first to compare three different groups (TLE surgery, TLE nonsurgery, and a healthy control group); (e) our study was powered to detect clinically meaningful differences between the healthy controls and the epilepsy surgery group. In conclusion, we believe that we demonstrated in our patient population that normal QOL, as assessed by the ESI-55, was achievable 3 years after temporal lobectomy in a group of adult patients with previously intractable TLE. Acknowledgment: We thank Miss Rana Kurdi for her help in statistical analysis of the results.
REFERENCES 1. Guldvog B, Loyning Y, Hauglie-Hanssen E, et al. Surgical versus medical treatment for epilepsy, II: outcome related to social areas. Epilepsia 1991;32:477–486. 2. Kellett MW, Smith DF, Chadwick DW. Quality of life after epilepsy surgery. J Neurol Neurosurg Psychiatry 1997;63:52–58.
933
3. Markand ON, Salanova V, Whelihan E, et al. Health-related quality of life outcome in medically refractory epilepsy treated with anterior temporal lobectomy. Epilepsia 2000;41:749–759. 4. McLachlan RS, Rose KJ, Derry PA, et al. Health-related quality of life and seizure control in temporal lobe epilepsy. Ann Neurol 1997;41:482–489. 5. Mikati MA, Comair Y, Ismail R, et al. Effects of epilepsy surgery on quality of life: a controlled study in a Middle Eastern population. Epilepsy Behav 2004;5:72–80. 6. Ho A, Ng K, Chan C, et al. Quality of life of people with epilepsy following temporal lobectomy: a preliminary report. Percept Motor Skills 2000;91:1035–1039. 7. Vickrey BG, Hays RD, Graber J, et al. A health-related quality of life instrument for patients evaluated for epilepsy surgery. Med Care 1992;30:299–319. 8. Vickrey BG. A procedure for developing a quality of life measure for epilepsy surgery patients. Epilepsia 1993;34(suppl 4):S22–S27. 9. Engel J Jr, Van Ness P, Ramussen T, et al. Outcome with respect to epileptic seizures. In: Engel J Jr, ed. Surgical Treatment of the Epilepsies. 2nd ed. New York: Raven Press, 1993:615. 10. Aydemir N, Ozkara C, Canbeyli, et al. Changes in quality of life and self-perspective related to surgery in patients with temporal lobe epilepsy. Epilepsy Behav 2004;5:735–742. 11. Cankurtaran E, Ulug B, Saygi S, et al. Psychiatric morbidity, quality of life, and disability in mesial temporal lobe epilepsy patients before and after anterior temporal lobectomy. Epilepsy Behav 2005;7:116– 122. 12. Lowe A, David E, Kilpatrick C, et al. Epilepsy surgery for pathologically proven hippocampal sclerosis provides long term seizure control and improved quality of life. Epilepsia 2004;45:237–242. 13. Walczak TS, Radtke RA, McNamara JO, et al. Anterior temporal lobectomy for complex partial seizures: evaluation, results, and long-term follow up in 100 cases. Neurology 1990;40:413–418. 14. Vickrey BG, Hays RD, Rausch R, et al. Outcomes in 248 patients who had diagnostic evaluations for epilepsy surgery. Lancet 1995;346:1445–1449. 15. Reid K, Herbert A, Baker GA. Epilepsy surgery: patient-perceived long-term costs and benefits. Epilepsy Behav 2004;5:81–87. 16. Gilliam F, Kuzniecky R, Meador K, et al. Patient-oriented outcome assessment after temporal lobectomy for refractory epilepsy. Neurology 1999;53:687–694. 17. O’Donoghue MF, Duncan JS, Sander JWAS. The subjective handicap of epilepsy: a new approach to measuring treatment outcome. Brain 1998;121:317–343. 18. Wiebe S, Rose K, Derry P, et al. Outcome assessment in epilepsy: comparative responsiveness of quality of life and psychosocial instruments. Epilepsia 1997;38:430–438. 19. Wiebe S, Blume W, Girvin J, et al. A randomized controlled trial of surgery for temporal lobe epilepsy. N Engl J Med 2001;345:311– 318. 20. Selai C, Elstner K, Trimble M. Quality of life pre and post epilepsy surgery. Epilepsy Res 2000;38:67–74. 21. Ettinger A, Reed M, Cramer J. Depression and comorbidity in community-based patients with epilepsy or asthma. Neurology 2004;63:1008–1014. 22. Mrabet H, Mrabet A, Zouari B, et al. Health-related quality of life of people with epilepsy compared with a general reference population: a Tunisian study. Epilepsia 2004;45:838–843. 23. Oyegbile T, Dow C, Jones J, et al. The nature and course of neuropsychological morbidity in chronic temporal lobe epilepsy. Neurology 2004;62:1736–1742. 24. Zhu D, Jin L, Xie G, et al. Quality of life and personality in adults with epilepsy. Epilepsia 1998;39:1208–1212. 25. Pirio Richardson S, Farias S, et al. Improvement in seizure control and quality of life in medically refractory epilepsy patients converted from polypharmacy to monotherapy. Epilepsy Behav 2004;5:343– 347.
Epilepsia, Vol. 47, No. 5, 2006
