From the Guidelines
Mesial temporal sclerosis can progress over time if left untreated or inadequately managed, leading to worsening seizures, cognitive decline, and psychosocial difficulties. The management of mesial temporal sclerosis (MTS) primarily focuses on controlling seizures through antiepileptic drugs (AEDs) as first-line therapy. Common medications include levetiracetam (500-3000 mg/day), carbamazepine (400-1200 mg/day), lamotrigine (100-400 mg/day), or oxcarbazepine (600-2400 mg/day), often requiring lifelong treatment. Unfortunately, about 60-70% of MTS patients develop drug-resistant epilepsy, necessitating surgical intervention.
Key Points to Consider:
- Anterior temporal lobectomy or selective amygdalohippocampectomy offers seizure freedom in 60-80% of cases, significantly improving quality of life.
- Before surgery, patients undergo comprehensive evaluation including video-EEG monitoring, high-resolution MRI, neuropsychological testing, and sometimes invasive EEG monitoring to confirm seizure origin.
- The progression of MTS typically begins with an initial precipitating injury (such as febrile seizures, infection, or trauma) in early childhood, followed by a latent period before seizures develop, usually in adolescence or early adulthood.
- Without effective treatment, MTS can lead to progressive hippocampal atrophy, worsening seizures, cognitive decline (particularly memory impairment), and psychosocial difficulties.
- Early surgical intervention in drug-resistant cases is recommended, as longer seizure duration correlates with poorer cognitive outcomes and reduced surgical success rates, as noted in recent guidelines such as those from the European Journal of Nuclear Medicine and Molecular Imaging 1.
From the Research
Management of Mesial Temporal Sclerosis
- The management of mesial temporal sclerosis (MTS) often involves pharmacological therapy, but the long-term prognosis is generally considered poor 2.
- Surgical therapy is frequently reported to be successful in treating MTS, with a higher proportion of patients becoming seizure-free compared to those receiving only pharmacotherapy 2.
- Antiepileptic drugs (AEDs) such as carbamazepine, valproate, and clobazam have been found to have high 12-month retention rates in patients with MTS 3.
- Newer AEDs, including brivaracetam, eslicarbazepine, lacosamide, perampanel, and retigabine, have shown potential effectiveness in treating MTS, but their efficacy is not significantly greater than that of older AEDs 4, 3, 5.
Progression of Mesial Temporal Sclerosis
- MTS can progress over time, with a longer duration of epilepsy associated with poorer prognosis and drug-resistance 5.
- Younger age at onset of seizures is also associated with poorer prognosis and drug-resistance 5.
- The presence of mesial temporal sclerosis (MTS) is a significant predictor of seizure freedom after surgical treatment, with patients with MTS being more likely to become seizure-free compared to those without MTS 6.
- Stereotactic EEG-guided laser interstitial thermal therapy (LITT) has been found to be a safe and effective alternative to selective amygdalohippocampectomy and anterior temporal lobectomy for MTS, with a significant proportion of patients achieving freedom from disabling seizures 6.