Bilateral ictal EEG is associated with better memory outcome after hippocampal sclerosis surgery

OBJECTIVE: To compare memory outcomes after surgery for unilateral hippocampal sclerosis (HS)‐associated epilepsy in patients with unilateral and bilateral ictal electrographic involvement. METHODS: We prospectively evaluated HS patients, aged 18‐55 years and IQ ≥70. Left (L) and right (R) surgical groups underwent noninvasive video‐EEG monitoring and Wada test. We classified patients as Ipsilateral if ictal EEG was restricted to the HS side, or Bilateral, if at least one seizure onset occurred contralaterally to the HS, or if ictal discharge evolved to the opposite temporal region. Patients who declined surgery served as controls. Memory was evaluated on two occasions with Rey Auditory‐Verbal Learning Test and Rey Visual‐Design Learning Test. Baseline neuropsychological test scores were compared between groups. Pre‐ and postoperative scores were compared within each group. Reliable change index Z‐scores (RCI) were obtained using controls as references, and compared between surgical groups. RESULTS: We evaluated 64 patients. Patients were classified as: L‐Ipsilateral (9), L‐Bilateral (15), L‐Control (9), R‐Ipsilateral (10), R‐Bilateral (9), and R‐Control (12). On preoperative evaluation, memory performance did not differ among surgical groups. Right HS patients did not present postoperative memory decline. L‐Ipsilateral group presented postoperative decline on immediate (P = 0.036) and delayed verbal recall (P = 0.011), while L‐Bilateral did not decline. L‐Ipsilateral had lower RCI Z‐scores, indicating delayed verbal memory decline compared to L‐Bilateral (P = 0.012). SIGNIFICANCE: Dominant HS patients with bilateral ictal involvement presented less pronounced postoperative verbal memory decline compared to patients with exclusive ipsilateral ictal activity. Surgery was indicated in these patients regardless of memory impairment on neuropsychological testing, since resection of the left sclerotic hippocampus could result in cessation of contralateral epileptiform activity, and, therefore, improved memory function.