Association of Piriform Cortex Resection With Surgical Outcomes in Patients With Temporal Lobe Epilepsy

IMPORTANCE: A functional area associated with the piriform cortex, termed area tempestas, has been implicated in animal studies as having a crucial role in modulating seizures, but similar evidence is limited in humans. OBJECTIVE: To assess whether removal of the piriform cortex is associated with postoperative seizure freedom in patients with temporal lobe epilepsy (TLE) as a proof-of-concept for the relevance of this area in human TLE. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used voxel-based morphometry and volumetry to assess differences in structural magnetic resonance imaging (MRI) scans in consecutive patients with TLE who underwent epilepsy surgery in a single center from January 1, 2005, through December 31, 2013. Participants underwent presurgical and postsurgical structural MRI and had at least 2 years of postoperative follow-up (median, 5 years; range, 2-11 years). Patients with MRI of insufficient quality were excluded. Findings were validated in 2 independent cohorts from tertiary epilepsy surgery centers. Study follow-up was completed on September 23, 2016, and data were analyzed from September 24, 2016, through April 24, 2018. EXPOSURES: Standard anterior temporal lobe resection. MAIN OUTCOMES AND MEASURES: Long-term postoperative seizure freedom. RESULTS: In total, 107 patients with unilateral TLE (left-sided in 68; 63.6% women; median age, 37 years [interquartile range {IQR}, 30-45 years]) were included in the derivation cohort. Reduced postsurgical gray matter volumes were found in the ipsilateral piriform cortex in the postoperative seizure-free group (n = 46) compared with the non–seizure-free group (n = 61). A larger proportion of the piriform cortex was resected in the seizure-free compared with the non–seizure-free groups (median, 83% [IQR, 64%-91%] vs 52% [IQR, 32%-70%]; P