Seizure 18 (2009) 193–196

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Seizure
journal homepage: www.elsevier.com/locate/yseiz

Seizure recurrence following epilepsy surgery: Is post-operative EEG helpful?

Georges A. Ghacibeh a,b,*, Jeffrey D. Smith b, Steven N. Roper c, Robin Gilmore b, Stephan Eisenschenk b
a
Northeast Regional Epilepsy Group, Hackensack University Medical Center, Comprehensive Epilepsy Center, 20 Prospect Avenue, Suite 800, Hackensack, NJ 07601, USA
b
University of Florida, Department of Neurology, P.O. Box 100236, Gainesville, FL 32610, USA
c
University of Florida, Department of Neurosurgery, P.O. Box 100265, Gainesville, Florida 32610, USA

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: We examined whether the relationship between interictal epileptiform discharges (IED) on
Received 8 August 2008 post-operative EEG and seizure recurrence after epilepsy surgery was different in patients with neocortical
Accepted 12 September 2008 and mesiotemporal resections.
Methods: We reviewed the records of 93 consecutive patients who underwent epilepsy surgery at our
Keywords: center and who had adequate post-operative follow-up and a post-operative EEG to determine the type of
Epilepsy surgery surgery, the recurrence of seizures and the presence of IED on post-operative EEG.
EEG
Results: Chi-square test revealed that for the entire group, there was a significant relationship between
Interictal epileptiform discharges
the presence of IED and seizure recurrence. However, this relationship was significant in neocortical
Seizure recurrence
surgery but not in mesiotemporal surgery. Time distribution of seizure recurrence revealed that in more
than half the cases, seizures recurred with the first 3 months. Time distribution was not influenced by the
presence of IED.
Conclusions: This study revealed that IED on early post-operative EEG correlate with seizure recurrence in
neocortical but not mesiotemporal surgeries and may be used to guide patient counseling in this group of
patients.
ß 2008 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

1. Introduction Intraoperative factors, such as electrocorticography (ECoG),13 and

Patients undergoing surgery for the treatment of medically
intractable epilepsy have variable rates of seizure remission.
Counseling patients regarding surgical outcome is challenging,
given the impact recurrent seizures can have on quality of life,
vocation, driving, family planning, and discontinuation of anti-
epileptic drugs.1–3 The prediction of post-surgical outcome remains
uncertain, but several factors have fairly reliable predictive value.
Preoperative predictors for post-operative seizure remission
include electrographic, structural and historical factors, such as
unilateral interictal epileptiform discharges (IED),4–7 MRI abnorm-
alities4,8 including hippocampal sclerosis5,6 and tumors,9 febrile
convulsions in childhood6 and complex partial seizures without
secondary generalization.10 Other preoperative factors, such as age of
onset, duration of epilepsy, and etiology remain controversial.5,8,11,12
* Corresponding author at: Northeast Regional Epilepsy Group, Hackensack
University Medical Center, Comprehensive Epilepsy Center, 20 Prospect Avenue,
Suite 800, Hackensack, NJ 07601, USA. Tel.: +1 201 996 3205; fax: +1 201 343 6689.
E-mail address: gghacibeh@gmail.com (G.A. Ghacibeh).
completeness of resection,9,14 are also controversial.
Post-operatively, early seizure recurrence after surgery has
reliably predicted a poor outcome,4,15,16 worse with generalized
seizures.10 Seizure freedom in the first post-operative year is
associated with good long term outcome.5,11 The presence of
interictal epileptiform discharges on the post-operative EEG has
also been studied, with conflicting results. Some studies showed a
strong predictive value4,5,10,11,13,14,17,18 and others showed no
predictive value.5,14,17,19,20 Conflicting results are likely due to a
number of factors. For example, there is no standard time to
perform a post-operative EEG, and centers that do perform them
routinely, set their own protocols. Furthermore, the studied
populations vary considerably among studies with the majority
of series focusing on anterior temporal lobectomy (ATL). Some
studies compared ATL to extratemporal resection,11,14,17 reveal-
ing better predictive value in the ATL patients. Other studies have
found a positive predictive value in neocortical parietal21 and
frontal22 resections.
In this study, we compared the predictive value of IED identified
on a 3-month post-operative EEG for seizure recurrence in patients
with mesiotemporal lobe epilepsy (MTLE) and patients with
neocortical epilepsy who underwent surgical resection.

1059-1311/$ – see front matter ß 2008 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.seizure.2008.09.003
194 G.A. Ghacibeh et al. / Seizure 18 (2009) 193–196
2. Methods
2.1. Subjects
All patients who underwent surgery for the treatment of
medically intractable epilepsy at the University of Florida between
January 1997 and December 2002 were identified. The electronic
medical records were reviewed including operative reports, clinic
notes and EEG reports.
2.2. Data collection
All surgeries were performed by the same neurosurgeon with
subspecialty training in epilepsy surgery. Operative reports were
reviewed to define the type of surgery. No patient was excluded
based on the type of resection or underlying pathology. Resections
were classified as mesiotemporal if the surgery was a standard
ATL,23 and neocortical for all other types of resections. Clinic notes
were reviewed up to the last available to determine the recurrence
of seizures. If seizures recurred, seizure type, date of recurrence
and anti-epileptic drug status were determined. Only focal motor,
complex partial (CPS) and generalized seizures (GTC) were
considered seizure recurrences. Patients who had persistence or
recurrence solely of auras were considered seizure-free. For
patients to be included in the analysis, a post-operative follow-
up of at least 2 years was required. Finally, post-operative EEG
reports were reviewed to assess for the presence of IED. Patients
who did not have a post-operative EEG were excluded from the
analysis. All EEGs were routine 30-min scalp studies performed
using a 21-channel digital recording. If more than one outpatient
EEG study was performed after surgery, the one recorded closest
to 3 months after surgery was used. All EEGs were reviewed
and interpreted by experienced electroencephalographers. Epi-
leptiform abnormalities were defined as sharp waves, spikes or
electrographic seizures.
2.3. Data analysis
The association between the presence of IED on post-operative
EEG and seizure recurrence was evaluated for the entire group of
patients, and in the two subgroups, mesiotemporal and neocortical
resection. In addition, the relationship between the presence of IED
and discontinuation of anti-epileptic drugs was also analyzed.
Statistical comparison was made using x2 or Fischer Exact test, as
appropriate. Statistical significance was set at a P value of less than
0.05.
3. Results
A total of 186 patients were identified. Of those, 90 had no post-
operative EEGs and 3 had insufficient clinic follow-up after their
surgery. Data on the remaining 93 patients were analyzed
(Table 1). EEGs were performed on average 106  22 days after
surgery. Patients were followed in clinic on average 40  20 months,
with a range of 24–99 months after surgery.
Patients who had only recurrent auras were grouped with
patients who remained seizure-free and compared to patients who
had seizure recurrence. For the entire sample, of the 29 (31%)
patients with IED, 17 (59%) had seizures and 12 (41%) remained
seizure-free. In contrast, of the 64 (69%) patients who had no IED,
18 (28%) had seizures and 46 (72%) remained seizure-free. Chi-
square analysis revealed a significant relationship (P = 0.005)
between the presence of IED and seizure recurrence, with an odds
ratio of 3.62 (95% CI: 1.445; 9.068). When the two surgery-type
groups were analyzed separately (Fig. 1), there was no significant
Table 1
Patient characteristics
Surgery type Total Side IED Seizure recurrence
Right Left
Mesiotemporal 69 37 32 15 22
Neocortical—All 24 16 8 14 13
Frontal 14 10 4 8 7
Temporal 9 6 3 5 5
Parietal 1 0 1 1 1
IED: Interictal epileptiform discharges on the post-operative EEG.
relationship in the mesiotemporal group (P = 0.446), but a
significant relationship is the neocortical group (P = 0.005), with
an odds ratio of 14.7 (95% CI: 1.97; 109.2).
Ongoing treatment with AEDs was also analyzed. Seventeen
patients had their AEDs discontinued at some point during follow-
up, and four of them (24%) had seizure-recurrence, all with ATL
surgeries. There was no significant relationship between the
presence or absence of IED and discontinuation of medications.
Two (17%) of the 12 patients who had IED and who remained
seizure-free, had all AEDs discontinued by the last follow-up, and
11 (24%) of the 46 patients with no IED and who remained seizure-
free had all AEDs discontinued by the last follow-up. Furthermore,
analysis was performed on the 17 patients who were taken off their
AEDs, to assess the predictive value of IED for seizure recurrence in
this group of patients (Fig. 2). Of the 3 patients who had IED, 1
(33%) had recurrent seizures and of the 14 patients without IED, 3
(21%) had recurrent seizures. The relationship was not statistically
significant (P = 0.6), however, the sample size is too small to draw
any conclusions.
The time distribution of seizure recurrence was also analyzed.
The time to first seizure (TFS) was calculated for each patient as the
period in months between surgery and the first seizure. For the
entire sample, TFS was: mean = 9.1  2.2; median = 2; for the ATL
group: mean = 11.4  3.2; median = 2; and for the neocortical group:
mean = 5.4  2; median = 1. Group comparison using a log rank test
revealed no significant difference (P = 0.09). In addition, the TFS of
patients with IED (mean: 6.7  2.3; median: 2) was not significantly
different (P = 0.182) from those without IED (mean: 11.5  3.6;
median: 2).
Time distribution analysis revealed that 57% of patients with
post-operative seizures experienced recurrence prior to the post-
operative EEG. Therefore, a second analysis was performed on
patients who had their first seizure more than 3 months after
Fig. 1. Relationship between the presence of interictal epileptiform discharges on
the post-operative EEG and seizure recurrence in the mesiotemporal and
neocortical surgery groups. The bars represent the number of patients with and
without IED. The black sections of the bars represent the proportion of patients with
seizure recurrence and the grey sections represent the proportion of patients who
remained seizure-free.
 G.A. Ghacibeh et al. / Seizure 18 (2009) 193–196
Fig. 2. Relationship between the presence of interictal epileptiform discharges on
the post-operative EEG and seizure recurrence after discontinuation of all anti-
epileptic drugs. The bars represent the number of patients with and without IED.
The black sections of the bars represent the proportion of patients with seizure
recurrence and the grey sections represent the proportion of patients who remained
seizure-free.
surgery, excluding all patients who had seizures prior to their post-
operative EEG from the analysis (Fig. 3). For the entire group, of the
19 patients with IED, 7 (37%) had seizure recurrence and 12 (63%)
remained seizure-free. In contrast, of the 54 patients without IED, 8
(15%) had seizures and 46 (85%) remained seizure-free. The
relationship between seizure recurrence and presence of IED was
again significant (P = 0.041). However, when analysis was per-
formed on each surgery-type separately, there was no significant
relationship between seizure recurrence and IED for either group.
4. Discussion
The results of this study indicate that interictal epileptiform
activity identified on outpatient EEG performed 3 months after
surgery for epilepsy is associated with a higher risk of seizure
recurrence, however, this relationship was present only for
neocortical surgery, and not for mesiotemporal surgery. Our
results are in agreement with previous studies that revealed the
lack of predictive value of IED on post-operative EEG in ATL
patients5,19,20 and in agreement with prior studies that found a
positive predictive value of post-operative EEG in extratemporal
epilepsy.21,22 However, other studies revealed results that were
inconsistent with our findings, including a strong predictive value
for post-operative EEG in temporal lobectomy patients14,17 and
Fig. 3. Relationship between the presence of interictal epileptiform discharges on
the post-operative EEG and seizure recurrence in the mesiotemporal and
neocortical surgery groups, excluding patients who had seizure recurrence prior
to 3 months after surgery. The bars represent the number of patients with and
without IED. The black sections of the bars represent the proportion of patients with
seizure recurrence and the grey sections represent the proportion of patients who
remained seizure-free.
195
a stronger predictive value for temporal versus extratemporal
patients.11,14,17
Inconsistencies between various studies may be related to
several factors. The timing of the EEG at 3 months after surgery
was chosen randomly at our center. Other studies reported different
timing of the EEG, including 6 months and 24 months.14,24 This
may have an impact on the occurrence of IED. Interictal epilepti-
form activity has been reported on EEGs performed early after brain
surgery without associated seizures.25 Therefore, it is conceivable
that EEGs performed earlier after surgery might potentially have a
higher chance of showing spikes and sharp waves due to the surgical
intervention itself, rather than the persistence of epileptogenic
cortex. Furthermore, if patients are followed longer, the classifica-
tion of outcome may change, as patients may remain seizure-free
for a period of time after surgery, with later recurrence of seizures.
Most studies tend to set their minimum follow-up time at 2 years
after surgery, however, some series had shorter follow-up.14,17
Finally, the main outcome measure analyzed is another important
confounding factor. In this study, we investigated the presence or
absence of post-operative seizures, and did not assess or classify
outcome.2 This is a significant difference between our studies and
others that focused on the relationship between IED and outcome.
Some patients may have seizures after their surgery and still qualify
for a fair outcome if they show significant improvement in seizure
control. Furthermore, in our study, about half the patients were
excluded from the analysis because they did not have a post-
operative EEG. Therefore, this study was not designed to examine
the outcome of epilepsy surgery.
In general, the occurrence of IED on EEG correlates strongly
with the diagnosis of epilepsy. This has been established in
multiple studies in which EEGs performed on subjects who never
had seizures rarely showed IED.26–29 However, the reverse is not
true. The absence of IED on a single EEG does not correlate as
strongly with the absence of seizures. In fact, IED are present in as
few as 29% of epilepsy patients on a single routine EEG, but
increase substantially with repeated EEGs.30,31 Therefore, longer
duration EEGs or repeated EEGs performed at different time-
intervals after surgery might have increased the chance of
capturing IED, especially if periods of sleep are included.
Ongoing treatment with AEDs represents another confounding
variable. Patients with IED on their post-operative EEG are
probably less likely to be taken off their AEDs. It is possible that
in some patients, seizure freedom is achieved due to the combined
benefit of surgery and the protective action of AEDs. Therefore,
patients who have IED and are seizure-free may very well have
recurrent seizures if they are taken off their AEDs. Analysis of the
relationship between IED and seizure-recurrence after withdrawal
of AEDs is therefore important in order to determine with certainty
whether IED indicates the presence of residual epileptogenic
cortex after surgery. In our study, the presence of IED on post-
operative EEG did not predict seizure-recurrence after disconti-
nuation of AEDs. However, the sample size (17 patients) was too
small to draw any definite conclusions. This kind of study requires
a more rigorous prospective design with longer follow-up periods.
Analysis of the time-distribution of seizure recurrence revealed
that in more that half the patients, seizures recurred within the
first 3 months. This is consistent with previous observations,
indicating that early recurrence of seizures often predicts poor
outcome.4,15,16 Therefore, we performed a separate analysis on
patients who had seizure recurrence more than 3-months after
surgery and found a significant relationship between IED and
seizure recurrence. Subgroup analysis did not reveal a statistical
significance for either group. This is likely related to the sample
size and the small number of patients with seizure recurrence,
especially in the neocortical group.
196 G.A. Ghacibeh et al. / Seizure 18 (2009) 193–196
The comparison of mesiotemporal to neocortical resection is
important, since several reports indicated a significant difference
in terms of surgical outcome between the two groups. Mesio-
temporal epilepsy and neocortical epilepsy with a focal MRI lesion
are usually considered good predictors of favorable surgical
outcomes.32–34 Several series indicate that neocortical resections
are generally less successful than temporal resections, with seizure
freedom achieved in 55–70% of temporal resections and 30–50% of
neocortical resections.35–38 This led to a recent decrease in the
enthusiasm to perform surgical resections on patients with non-
lesional neocortical epilepsy.36,39–42 The difference in outcome
may be related to a fundamental difference in the surgery itself and
in the pathophysiology of the type of epilepsy—the mechanism of
seizure evolution in the hippocampus is different from that of the
neocortex. The key to successful epilepsy surgery is complete
resection of the epileptogenic zone. This requires an accurate
localization of the epileptic focus, which can be difficult in
neocortical epilepsy, especially in the absence of an MRI lesion.
Therefore, the relationship between seizure freedom and the
completeness of the surgical resection may be stronger in
neocortical than mesiotemporal epilepsy, however, this relation-
ship needs to be studied systematically. Furthermore, the question
of whether the persistence of residual epileptogenic cortex is more
likely to produce IED in neocortical versus mesiotemporal
surgeries also needs to be answered.
Our study demonstrates that persistence of IED on an EEG
obtained 3 months after surgery is associated with a higher risk
of seizure recurrence and the absence of IED predicts a better
chance for seizure freedom in patients with neocortical but not
mesiotemporal epilepsy. Our results therefore indicate that the
routine performance of EEGs in the early post-operative period is a
useful prognostic tool in selected patients. However, the most
relevant clinical question is the ability to predict the risk of seizure
recurrence after discontinuation of AEDs. Therefore, further
research should examine the predictive value of post-operative
EEGs performed at different time intervals after surgery, especially
in the subgroup of patients who discontinue AEDs.
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