Intractable temporal lobe epilepsy with rare spikes is less severe than with frequent spikes

Objective: To analyze clinical, electrophysiologic, and neuroradiologic characteristics of a group of patients with nonlesional intractable temporal lobe epilepsy (TLE) and rare or absent interictal epileptiform abnormalities (IEA). Methods: Between 1990 and 2000, 31 patients (11 men; mean +/- SD age 34.3 +/- 11.7 years) with nonlesional intractable TLE were consecutively selected on the basis of the absence or paucity of IEA (<1/h) on serial scalp EEG recording; these were defined as oligospikers. The clinical and laboratory characteristics of oligospikers were compared with those of a group of 27 age-matched control subjects (10 men; mean +/- SD age 38.5 +/- 11 years), randomly selected from a pool of patients with nonlesional TLE with frequent IEA. Results: Oligospikers showed a later age at seizure onset (mean SD 19.1 +/- 14.4 versus 10.2 +/- 7.4 years; p = 0.004), lower monthly frequency of complex partial seizures (median 6 versus 12; p = 0.035), lower incidence of secondarily generalized tonic-clonic seizures (10 versus 81%; p < 0.001), and no status epilepticus (0 versus 22%) than control subjects. Also, hippocampal. atrophy (HA) was less commonly found in oligospikers (55 versus 96%; p = 0.001). However, there were no differences between the two groups in the frequency of family history of epilepsy, risk factors, febrile convulsions, and type of medication. Twenty-three (74%) oligospikers and 25 (93%) control patients underwent either a selective amygdalohippocampectomy or corticoamygdalohippocampectomy. Excellent surgical outcome (Engel's Class Ia) was found in 14 of 23 (61%) oligospikers and 17 of 25 (67%) control patients. Conclusions: This study identified a subgroup of patients with nonlesional intractable TLE with no or few IEA. Oligospikers have a later age at seizure onset, less frequent and less severe seizures, besides a lower incidence of HA. The similarity of etiologic factors compared with patients with frequent IEA suggests that the rarity of spikes could reflect a disease not really distinct but less severe, even though still intractable and incapacitating enough to consider surgery. In spite of the absence or paucity of IEA, oligospikers have excellent surgical outcome.