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IMPACT OF TEMPORAL LOBE RESECTION ON APPRECIATION OF MUSIC
AND FACIAL EMOTIONS
Submitted for MCh Neurosurgery
Sree Chitra Tirunal Institute for Medical Sciences & Technology
Thiruvananthapuram
IMPACT OF TEMPORAL LOBE RESECTION ON APPRECIATION OF MUSIC
AND FACIAL EMOTIONS – A PROSPECTIVE NON-RANDOMISED
OBSERVATIONAL STUDY
Submitted for MCh Neurosurgery
By
Dr. Sridutt B S
October 2016
Department of Neurosurgery
Tirunal Institute for Medical Sciences & Technology
Thiruvananthapuram – 695011
IMPACT OF TEMPORAL LOBE RESECTION ON APPRECIATION OF MUSIC
RANDOMISED
Tirunal Institute for Medical Sciences & Technology
IMPACT OF TEMPORAL LOBE RESECTION ON APPRECIATION OF MUSIC
AND FACIAL EMOTIONS
Submitted by :
Programme :
Month & Year of submission :
IMPACT OF TEMPORAL LOBE RESECTION ON APPRECIATION OF MUSIC
AND FACIAL EMOTIONS – A PROSPECTIVE NON-RANDOMISED
OBSERVATIONAL STUDY
Dr. Sridutt B S
MCh Neurosurgery
October 2016
IMPACT OF TEMPORAL LOBE RESECTION ON APPRECIATION OF MUSIC
RANDOMISED
MCh Neurosurgery
CERTIFICATE
This is to certify that the thesis entitled “Impact of temporal lobe resection on
appreciation of music and facial emotions – a prospective non-randomised
observational study” is a bonafide work of Dr. Sridutt B S and was conducted in the
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthpuram, under my guidance and supervision.
Prof. Suresh Nair N
Head of Department,
Department of Neurosurgery,
SCTIMST,
Thiruvananthapuram
DECLARATION
The thesis entitled “Impact of temporal lobe resection on appreciation of music and
facial emotions – a prospective non-randomised observational study” is a consolidated
report based on a bonafide study of the period from July 2015 to September 2016, done by me
under the Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Thiruvananthpuram.
This thesis is submitted to SCTIMST in partial fulfillment of the rules and regulations for MCh
Neurosurgery examination.
Dr. Sridutt B S
Department of Neurosurgery,
SCTIMST,
Thiruvananthpuram
ACKNOWLEDGEMENT
This project work is the end result of the combined efforts of not just me, but a lot of people
working along with me and with the invaluable guidance of my teachers. I take this opportunity
to express my gratitude in all humility to them.
First up, I would express my humble gratitude to God almighty for giving me the
opportunity to study and practice medicine and help humanity in whatever little way I
presumably can.
Prof. Suresh Nair N, Head of Department, Neurosurgery, SCTIMST, besides being a great
surgeon, is a wonderful human being. His guidance, valuable inputs, expert supervision and
untiring help throughout the period of this study has made it possible for this work to take its
present form. Without his knowledge and foresight it would have been impossible to complete
this project in time. His uncompromising work ethics admixed with his remarkable sense of
humor has kept us on our toes throughout and helped us steer through times of darkness and
gloom. I take great pride in addressing myself as his student. His teachings would light the long
and tedious road that lies ahead towards success.
Prof. Mathew Abraham, Professor, Neurosurgery, has been my principal guide for this
project. He is a versatile surgeon and a treasure house of resourcefulness. Without his expertise
in this field, it would have been next to impossible for me to recruit subjects for this project and
evaluate them. He has stood by me at each and every step of this project. His constant
encouragement and guidance was quintessential for completion of this study.
I am highly indebted to Dr. George C Vilanilam, Associate Professor, Neurosurgery, for
providing all the resources and every possible help and encouragement needed for completion
of this project. His constant reminders and deadlines were invaluable for the progress of
this work. I am thankful to him for all his untiring efforts.
I take this opportunity to express my deep sense of gratitude and regards for my teachers Prof.
Girish Menon, Dr. Easwer H V, Dr. Krishnakumar K, Dr. Jayanand Sudhir B and Dr.
Prakash Nair for their kind help, consistent encouragement and healthy suggestions.. Their vast
knowledge, acute perception and critical analysis aided me in innumerable ways. Their cooperation
and assistance was indispensible.
I express my sincere gratitude to Mrs. Renu Joji, for her invaluable support in conducting the
neuro-psychological test in this study.
I also express my gratitude to my friends and colleagues Dr. Ranjit Rangnekar,
Dr. Vihang Sali and Dr. Vishal Thakur who have always been there at times of need and ever
ready to lend a helping hand. I express my sincere gratitude to Dr. Bimal Sahoo,
Dr. Gopikrishnan, Dr. Pankaj Shivhare, Dr. Shashank, Dr. Gograj Garhwal, Dr. Nithin Raj,
Dr. Palak Jaiswal and Dr. Pradeepanand Vaidya who have provided me with invaluable
assistance whenever required.
I take this opportunity to express my gratitude and indebtedness to my parents who have been a
pillar of support throughout my career and have imbibed in me the values and principles which
have kept me in good stead. I also thank my wife and other family members for being a constant
source of support and encouragement.
October 2016 Sridutt B S
TABLE OF CONTENTS
1. INTRODUCTION .............................................................................................. 1
2. REVIEW OF LITERATURE ........................................................................... 3
2.1 ANATOMY OF TEMPORAL LOBE ............................................................ 3
2.2 PHYSIOLOGY OF TEMPORAL LOBE ....................................................... 8
2.3 NEURO-COGNITIVE IMPLICATIONS OF ATL ..................................... 14
3. AIMS & OBJECTIVES .................................................................................. 26
4. MATERIALS & METHODS ......................................................................... 27
5. OBSERVATIONS & RESULTS .................................................................... 35
6. DISCUSSION ................................................................................................... 69
7. CONCLUSION ................................................................................................. 82
8. REFERENCES ................................................................................................. 83
9. ANNEXURES ................................................................................................... 88
9.1 MASTER CHART ....................................................................................... 88
9.2 KEY TO MASTER CHART ....................................................................... 91
9.3 IEC APPROVAL LETTER ......................................................................... 92
9.4 ORIGINALITY REPORT ........................................................................... 94
9.5 CONSENT FORMS ..................................................................................... 95
9.6 CASE PROFORMA .................................................................................... 97
1
1. INTRODUCTION:
Surgery is frequently considered as the treatment of choice for patients with
medically refractory temporal lobe epilepsy. Anterior temporal lobectomy (ATL)
along with resection of mesial temporal structures i.e. with amygdalo-
hippocampectomy is the most commonly performed epilepsy surgery worldwide.
ATL is generally considered a safe surgery with long term clinically significant
neuro-cognitive sequelae occurring in only a small fraction of patients undergoing
ATL. Nevertheless, ATL is not completely devoid of neuro-cognitive risk. Several
studies have reported both short term and long term neuro-cognitive changes
associated with ATL. These changes may at times be serious enough to necessitate
interventions and rehabilitative measures to reduce the morbidity of patients in
performing activities of daily living.
Most studies in literature that measure outcome after epilepsy surgery, the quality
of life profile and neuro-cognitive outcome are usually measured at 6 months to
one year post surgery. Following up these patients for longer intervals has
frequently shown that the neuro-cognitive functions for most patients will
gradually improve over time and ultimately attain levels that are almost
comparable to pre-operative values.
2
However, there is no clear consensus regarding the best time interval for evaluating
neuro-cognitive function after epilepsy surgery to detect any early impairments
that may exist so that such patients may be expeditiously directed toward the
appropriate cognitive rehabilitation therapy. The data on early cognitive
impairments in such patients needs to be evaluated to address their needs in terms
of cognitive rehabilitation and other interventions.
Therefore, the aim of our study is to compare and contrast the pre-operative
neuropsychological profile in patients undergoing ATL for epilepsy with
immediate postoperative and early post-operative (at 3 months) performance. We
hypothesized that short-term evaluation beginning at six weeks after resective
epilepsy surgery would reveal early changes in neuro-cognitive function that may
help to identify patients who may need expeditious referral to rehabilitation, which
may ultimately influence decisions such as early return to work or school.
3
2. REVIEW OF LITERATURE:
2.1 ANATOMY OF THE TEMPORAL LOBE:
The temporal lobe is one of the five lobes of the cerebrum. The temporal lobe lies
inferior to the sylvian fissure, which separates it from the frontal and parietal lobes.
The temporal lobe is limited posteriorly by an imaginary line joining the pre-
occipital incisure to the parieto-occipital sulcus.
For descriptive purposes, the temporal lobe is studied with reference to 3 surfaces
– the lateral surface, the medial surface and the inferior surface.
Lateral surface - Lateral surface is divided into three parallel gyri by two sulci.
The superior and inferior temporal sulci divide the lateral surface into superior,
middle and inferior temporal gyri. These gyri terminate anteriorly at the temporal
pole. Along its superior margin, the superior temporal gyrus is continuous with the
gyri on the floor of the posterior ramus of the sylvian fissure. These gyri vary in
number and they extend anterolaterally around the insula as transverse temporal
gyri of Heschl. Gyri of Heschl and adjoining area of superior temporal gyrus forms
the primary auditory cortex (Area 42).
The middle temporal gyrus lies between the superior and inferior temporal sulci.
The temporal horn and the ambient and the crural cisterns are located deep to the
middle temporal gyrus. The inferior temporal gyrus lies below the inferior
4
temporal sulcus and continues around the inferior border of the hemisphere to form
the lateral part of the basal surface.
Fig.1: Lateral surface of Temporal Lobe
Inferior surface - The basal surfaces of the temporal and occipital lobes are formed
by the same gyri that continue from anterior to posterior across their uninterrupted
surface. From medial to lateral are the parahippocampal and occipitotemporal gyri
and the basal surface of the inferior temporal gyrus. The parahippocampal gyrus
extends backward from the temporal pole to the posterior margin of the corpus
callosum and thence on it continues posteriorly to blend into the isthmus of the
cingulate gyrus and the lingula.
5
The collateral sulcus begins near the occipital pole and extends anteriorly, parallel
and lateral to the calcarine sulcus. Posteriorly, it separates the lingula and
occipitotemporal gyrus, and anteriorly, it courses between the parahippocampal
and the occipitotemporal gyri. The occipitotemporal sulcus courses parallel and
lateral to the collateral sulcus and separates the occipitotemporal gyrus and basal
surface of the inferior temporal gyrus.
Medial surface – The medial surface of the temporal lobe is formed predominantly
by the rounded medial surfaces of the parahippocampal gyrus and uncus. It is
formed by three longitudinal strips of neural tissue, located one above the other,
which are interlocked with the hippocampal formation.
The most inferior strip is formed by the rounded medial edge of the
parahippocampal gyrus. The middle strip is formed by the dentate gyrus, a narrow
serrated strip of gray matter located on the medial surface of the hippocampal
formation. The superior strip is formed by the fimbria of the fornix. The
parahippocampal and dentate gyri are separated by the hippocampal sulcus. The
dentate gyrus and the fimbria are separated by the fimbriodentate sulcus.
6
The parahippocampal gyrus also extends around the lower border to form the
medial part of the basal surface of the temporal lobe, where it is separated from the
medially projecting uncus by the rhinal sulcus.
Fig 2: Medial surface of Temporal Lobe
Uncus, is the medially projecting anterior part of the parahippocampal gyrus.
When viewed from above or below, it has an angular shape with anterior and
posterior segments that meet at a medially directed apex.
Amygdaloid nucleus, so named because it resembles an almond is situated entirely
within uncus. It forms the anterior wall of the temporal horn. It fuses with the tip of
the tail of the caudate nucleus. The amygdala gives rise to the stria terminalis,
7
which courses between the thalamus and caudate nucleus deep to the
thalamostriate vein.
Hippocampus is a curved elevation of gray matter; approximately 5 cm long.It runs
along entire length of the medial part of floor of the temporal horn. The Dentate
gyrus runs along the medial edge of hippocampus. The hippocampus blends into
and forms the upper part of the posterior uncal segment.
The hippocampus, the parahippocampal gyrus and the dentate gyrus together form
the hippocampal formation. The hippocampus is divided into three parts: head,
body and tail. The head, directed anteriorly, has 3-4 digitations, resembling paw of
sea-horse; hence called “pes hippocampus”. The body of the hippocampus extends
along the medial part of the floor of the temporal horn, narrowing into the tail that
disappears as a ventricular structure.
The convex ventricular surface is covered with ependyma. Beneath this lies a thin
layer of white matter – alveus. The alveus consists of nerve fibers which originated
in the hippocampus. These fibers converge medially to form a bundle, viz. fimbria.
The fimbria becomes continuous with the crus of fornix.
8
Fig 3: Anatomy of Hippocampus
2.2 PHYSIOLOGY OF TEMPORAL LOBE:
Cyto-architectonically the human temporal lobe is divided into 10 Brodmann’s
Areas but there is a high likelihood to be many more. Apart from the eloquent
temporal cortex some key subcortical regions involved intimately with the
functioning of the temporal lobe include the Limbic system, Amygdala and the
Hippocampal formation.
The temporal lobe is involved in 3 core sensory functions:
(a) Processing auditory information and Language and interpretation of emotional
dimension of auditory stimuli
(b) Processing visual information with regards to object identification and
9
emotional aspect interpretation of visual stimuli
(c) Learning and memory
It is well known that the temporal cortex is mainly responsible for processing
primary auditory stimuli and their sensory and emotional aspects. The first step in
perception of auditory stimulus takes place in the primary auditory area in the
superior temporal gyrus(STG) corresponding to Brodman’s area 41 & 42. What
happens subsequently, to the perceived auditory stimulus is a matter of extensive
scientific research. Schirmer et al.45
proposed that processing and subsequent
perception of auditory information occurs along 3 streams in the human temporal
lobe:
(1) a posterior stream going through the superior temporal sulcus which subserves
sound embodiment;
(2) a ventral stream passing through the middle temporal gyrus for conceptual
processing of auditory stimuli and
(3) an anterior stream extending along the superior temporal gyrus upto the
temporal pole for the purpose of semantic processing.
Thus the temporal cortex is extensively involved not only in perception of auditory
stimulus but also in processing the different aspects of the auditory stimuli like
emotional and semantic processing. Regarding the interpretation of the emotional
10
component of the auditory information, the amygdala has been shown to play a
vital role in interpretation of emotional vocalizations. Several studies have shown
the amygdala to be activated by emotional vocalizations, more so specifically
emotional prosody of words and sentences.11,12,56
Literature has abundant examples of incriminating the temporal cortex in the
process of visual & emotional perception. Haxby et al.17
proposed a visual
perception model in which it is hypothesized that primary visual information is
initially processed in the primary visual area in the occipital cortex (V1) and then
transmitted along a ventral pathway leading from the visual cortex (V1) to the
inferior temporal gyrus (ITG). The Inferior temporal gyrus contains an area of
eloquent cortex known as the Fusiform Face Area (FFA) which primarily
subserves the function for recognizing faces and this process is enhanced when this
facial information has an added emotional component to it. So, it is pretty evident
that the temporal cortex has an important role in interpretation of visual stimuli.
With regards to the variety of visual stimuli that humans are encountered with, it is
not only necessary to interpret the visual stimulus, but also there is an adaptive and
evolutionary need to decode the emotional component of this visual information.
One of the key areas of the temporal lobe involved in decoding emotional facial
11
information is the amygdala. In 1939, Heinrich Kluver and Paul Bucy reported
from their animal experiments on monkeys that the amygdala seems to be
quintessential to perceive fearful signals. This finding was extrapolated to humans
by Lanteaume et al.26
who in their study were able to incite negative states like fear
and sadness via electro-physiologic stimulation of the amygdala. Several studies in
humans have proposed that the connections between the amygdala and the Face
Area(FFA) on the Inferior Temporal Gyrus is altered by emotional perception.8,34,53
With respect to the specific role of amygdale in emotional perception, it is
currently postulated that it is important in detecting “salience” which is meant to be
a general feature of emotion.1,39,41
The predominant function of amygdala is to
facilitate perception processing through reciprocal connections with the sensory
cortex53,54
. The output of the amygdala is streamed towards, both, the areas of the
brain that govern bodily responses to stimuli (through the endocrine system and
autonomic nervous system), and also to the primary and associative areas like the
extrastriate visual system, the Fusiform Face Area in Inferior Temporal Gyrus
(ITG) , and the primary auditory area in the superior temporal gyrus (STG).
The precise role of the temporal cortex and its associated structures in processing
visual information along with its emotional component has been extensively
studied in patients undergoing anterior temporal lobectomy (ATL) and amygdalo-
12
hippocampectomy(AH) for lesional epilepsy. ATL with AH is known to affect the
perception facial emotional recognition and emotional situational recognition.36
The proposed hypothetical explanation for this, is the reduced modulation of the
amygdala on the ventral visual processing pathway and in the case of recognition
of facial emotions, on the fusiform face area (FFA).
Thus, the summary of current literature points out that, the temporal cortex is
responsible to decode the sensory value of a visual stimulus and the amygdala is
responsible for decoding the attached emotional component of the visual stimulus.
Thus, we hypothesize that a person who has undergone anterior temporal
lobectomy, will have a deficit not only in recognizing faces but also in decoding
the emotional aspect of the facial information and the situations they are involved
in.
The left and right medial temporal systems are found to sub serve different types of
material-specific information, mostly in accordance with the pattern of cerebral
language dominance.6,30,33,52
Learning and retention of verbal materials is
associated with the left temporal memory system, and that of nonverbal materials
is associated with the right temporal memory system, assuming a left cerebral
language dominance.
13
Lee et al.27
surmised a meta-analysis of studies related to memory decline after
temporal lobe dysfunction and concluded that verbal memory is lateralized in the
left hemisphere and that verbal memory tasks are sensitive to left temporal
dysfunction. The data for lateralization of nonverbal memory in the right
hemisphere is not entirely conclusive but usually right temporal dysfunction
manifests as a decline in non verbal memory.
Jones-Gotman et al.24
reported that patients with left temporal epilepsy showed a
retention deficit for a word list, whereas those with right temporal epilepsy showed
impaired learning of a design list. Similar findings were reported by Baxendale et
al.2 who observed that patients with left hippocampal sclerosis performed more
poorly than those with right hippocampal sclerosis on immediate and delayed prose
recall.
The scope and severity of human memory decline resulting from a bilateral
resection of the temporal lobe can best be captured in the study of the noted patient
H.M.46
who became amnesic in 1953 as the result of this surgical procedure for
control of his seizures. The anterograde amnesia that he had presented with
manifested as a dramatically impaired capacity for learning new material, or for
recollecting events after a distraction.
14
In summary, the Left temporal lobe predominantly subserves auditory and verbal
memory and the Right temporal lobe serves the purposes of visual memory.
Multimodal perception and memory encoding is mainly accomplished by the
participation of both temporal lobes in concert.
2.3 Neuro-Cognitive implications of Anterior Temporal Lobectomy (ATL) :
Surgery is often considered as the treatment of choice for drug resistant temporal
lobe epilepsy. Anterior Temporal Lobectomy (ATL) with Amygdalo-
hippocampectomy is the most commonly performed epilepsy surgery in patients
with refractory temporal lobe epilepsy . ATL is generally considered a safe surgery
with long term clinically significant neuro-cognitive sequelae occurring in only a
small fraction of patients undergoing ATL.
Wiebe et al.55
reported an overall long term persistent neuro-cognitive disability in
about 2-3% of patients undergoing ATL and concluded that it was a safe surgical
procedure from a long term prospective. Nevertheless, ATL is not completely
devoid of neuro-cognitive risk. Several studies have reported both short term and
long term neuro-cognitive changes associated with ATL. These changes may at
times be serious enough to necessitate interventions and rehabilitative measures to
reduce the morbidity of patients in performing activities of daily living.
15
Measuring the effects of ATL on neuro-cognition in epilepsy patients poses certain
singular challenges. First and foremost epilepsy is not a uniform condition, but is
infact heterogeneous in terms of clinical, demographic, and etiologic dimensions.
Precise predictions of outcome after any surgical intervention cannot be
generalized and an individualistic approach has to be adopted for individual
patients defining both surgical risks and benefits taking into account both
neurologic and neuropsychological factors. Secondly, epilepsy by virtue of being a
chronic condition, itself carries the probability of cognitive decline and reduced
psychological, vocational and social performance and compromised quality of
life.10,20,49
For the above mentioned reasons, routine statistical tools provide an overall trend
towards a particular neuro-cognitive deficit or benefit. Some empirically based
techniques for calculating individual change, like the Reliability Change Index
(RCI) and Standardized Regression-Based (SRB) change scores provide more
accurate and dependable risk estimates as compared to other measures for
cognitive changes after epilepsy surgery, and are now considered as the yard stick
in monitoring neuro-cognitive change after epilepsy surgery.5,7,21,43,51
16
Impact of ATL on IQ and Cognitive function:
Several studies in literature have investigated the impact of temporal lobe resection
on IQ and cognitive outcomes. But with regards to short term cognitive outcomes
only a handful of studies are available. Lee et al.28
, in their study on short term
outcome of ATL on cognition found that 39% of patients in their series had
improvements in IQ. Sherman et al.48
conducted a meta-analysis of all published
literature regarding cognitive outcome after ATL, and they reported in their series
of a 16 % improvement in IQ and psychomotor speed. Hence it is almost uniformly
agreed to upon in literature that epilepsy surgery carries an inherent benefit of an
increased psychomotor and cognitive performance in the post-operative period.
The exact neuro-physiological basis for improvement in IQ is yet to be elucidated
but it has been postulated that improvement in IQ is a reflection of
reduction/elimination of seizures post-operatively. The improvement in IQ may
also be partly be explained by patients having a reduced intake of anti-epileptic
medications in the post-operative period, with literature replete with evidence of
obtunding effect of these medications on the neuro-cognitive functions.29,31
Impact of ATL on Musical abilities:
17
Cortical resection studies using patients with intractable temporal lobe
epilepsy have shown deficits in discrimination of various musical stimuli
following Right ATL but not Left ATL, suggesting that hemispheric
specialization for music may have greater involvement of the right hemisphere
as compared to the left hemisphere.25
Milner et al.32
reported in their study that
ability to appreciate musical attributes showed greater decline in patients
undergoing Right ATL as compared to Left ATL. Shankweiler et al.47
used
electronically generated pure tones and intonations with differing musical
attributes and reported that ability to discriminate the different parameters of music
showed greater decline in patients with Right ATL as compared to Left ATL.
However, Hanschen et al.16
in their study, suggested that the right hemisphere was
involved in appreciation of gross attributes of music and the left hemisphere was
involved for appreciating certain attributes of music like pitch and rhythm. In their
report, Hanschen et al. revealed impairment in rhythm discrimination, reading
musical notation and detailed musical analysis following left hemisphere
damage.
18
These seemingly contradictory results are attributable to inconsistent
definitions of “musical processing” and differences in the types of stimuli
employed. As with other forms of cognitive processing, differential
hemispheric participation may depend on specific computational requirements
for aspects of musical processing (discrimination vs. perception vs. judgment)
and which component of music is being processed (pitch, rhythm, tempo,
etc.). It is unlikely that perception of individual tones, pitches, three or four
note melodies, electronically-generated sounds or excerpts from musical
pieces require the same type of processing. Hence appreciation of music and its
finer attributes may infact be possible only by bi-hemispheric participation, with
the right and left temporal lobes working in tandem to achieve the end result.
Earlier studies have focused on post-operative examination without elucidating
the relationship between pre- and post-operative performance. The present
study addresses these issues by using a comprehensive standardized battery
of musical aptitude tests administered to unilateral temporal lobe epileptics
before and after anterior temporal lobectomy.
Impact of ATL on multi-modal perception:
19
The temporal lobe, by virtue of its extensive involvement in processing visual and
auditory stimuli, plays an important role in multi-modal perception like recognition
of faces, facial emotion perception and emotional situation recognition.
Dulay et al.9 reported that patients undergoing ATL may have a transiently reduced
ability to recognize familiar faces. They also found that patients with temporal
lobectomy had a reduced ability to interpret and adapt to various social situations
due to obtunding of emotional perception after resection of anterior temporal lobe.
Gosselin et al.14
in their study, concluded that facial emotion interpretation was
most probably represented in a multimodal fashion in both temporal lobes and
hence resection of one temporal lobe is unlikely to significantly affect the ability to
decode facial emotions.
Both Dulay et al.9 and Gosselin et al.
14 had reported a non-specific decline in
general emotion understanding and social adaptation of patients with ATL in the
first 6 months of follow-up. Till date no literature is available that has conclusively
reported the implications of ATL on emotional situation adaptation and emotional
situation recognition.
Impact of ATL on Memory:
20
Memory decline represents one of the primary neuropsychological morbidities of
ATL.6,52
The right and left temporal lobes are found to sub serve different types of
material specific information, mostly in accordance with the pattern of cerebral
language dominance. Learning and retention of verbal materials is associated with
the left temporal memory system, and that of nonverbal materials like visual and
facial information is associated with the right temporal memory system, assuming
a left cerebral language dominance.30,33
Lee et al.27
surmised a meta-analysis of studies related to memory decline after
temporal lobe dysfunction and concluded that verbal memory is lateralized in the
left hemisphere and that verbal memory tasks are sensitive to left temporal
dysfunction. The data for lateralization of nonverbal memory in the right
hemisphere is not entirely conclusive but usually right temporal dysfunction
manifests as a decline in non verbal memory.
Jones-Gotman et al.24
reported that patients with left temporal epilepsy showed a
retention deficit for a word list, whereas those with right temporal epilepsy showed
impaired learning of a design list. Similar findings were reported by Baxendale et
al.21
who observed that patients with left hippocampal sclerosis performed more
poorly than those with right hippocampal sclerosis on immediate and delayed prose
recall.
21
The scope and severity of human memory decline resulting from a bilateral
resection of the temporal lobe can best be captured in the study of the noted patient
H.M.46
who became amnesic in 1953 as the result of this surgical procedure for
control of his seizures. The anterograde amnesia that he had presented with
manifested as a dramatically impaired capacity for learning new material, or for
recollecting events after a distraction. Since then, much research effort has been
invested in examining the role played by the temporal lobe in human memory.
An impairment of verbal memory has consistently been associated with resection
of the left dominant temporal lobe, whereas nonverbal memory deficits have been
less reliably observed after resection from the right temporal lobe.37
Numerous
other studies supported the observations that resection from the left ATL is
associated with postoperative decline in learning or retention of various types of
verbal material including words 23
and prose.13
Saykin et al.44
in their study reported that patients with right ATL showed decline
in nonverbal memory but improvement in verbal memory whereas those patients
with left ATL showed a decline in verbal memory but improvement in nonverbal
memory.
22
Ivnik et al.22
concluded that left ATL was found to impair immediate recall for
verbal materials (California Verbal Learning Test and a low-imagery word-
recognition task) but at the same time enhance immediate recall for nonverbal
material (Facial Recognition Memory Test and a modified Corsi Block task).The
review of published literature provides clear data that Left temporal resection
affects verbal memory and right temporal resection predominantly affects non-
verbal memory.
From the above mentioned data, it is quite clear that surgery for epilepsy does
indeed result in a certain degree of neuro-cognitive change albeit the change be
either positive or negative. The exact mechanisms by which either deficit or benefit
over neuro-cognitive functions occur after ATL are still being elucidated. However
the evidence from literature can be utilized to formulate discussions regarding
operative risks with prospective patients willing to undergo surgery for epilepsy.
Despite literature having evidence in abundance with regards to the changes in
cognitive functions after epilepsy surgery, ATL still continues to be the most
common surgical procedure performed worldwide for refractory temporal lobe
epilepsy. One commonly observed chief motivator for patients to undergo epilepsy
surgery happens to be the social stigma aligned with seizures, as the dread of
potential post-operative cognitive decline is a far cry to the optimism the patient
23
has of leading a seizure free life. Other factors may include non-compliance to a
drug schedule or adverse effects of the anti-epileptic medications.
Most studies in literature that measure outcome after epilepsy surgery, the quality
of life profile and neuro-cognitive outcome are usually measured at 6 months to
one year post surgery. Following up these patients for longer intervals has
frequently shown that the neuro-cognitive functions for most patients will
gradually improve over time and ultimately attain levels that are almost
comparable to pre-operative values. Grammaldo et al.15
, in their study found out
that those patients undergoing ATL, particularly on the left side, mainly showed
impairment in verbal memory at one year of follow-up. However, it was also found
during long term follow-up of 2-4 years, that a majority of those patients with such
an impairment at 1 year, did regain some or most of the lost function and return to
a level that was almost similar to the pre-operative baseline, resulting in a very
minimal difference pre- and postoperatively for the entire group.
In a similar study, Helmstaedter et al.18
reported that patients undergoing ATL had
memory deficits post surgery (at around 6 months – 1 year) but they also found that
24
such patients demonstrated a recovery of memory function at long-term follow-up
of around 2–10 years.
Hence it is well established from review of literature that epilepsy surgery may
lead to cognitive deficits or at times even improvements. Also well documented is
the fact that such deficits gradually improve over long term follow-up so that many
patients almost reach their pre-operative baseline values. Knowledge of the timing
of such deficits is essential, as earlier intervention can potentially lessen the burden
of such deficits on a patient's quality of life.
Research has demonstrated the benefits of early intervention in neurocognitive
treatment, especially in the case of preterm infants50
, cognitive decline35
, and
following traumatic brain injury.38
Similarly, early intervention with individual
and group based interventions is effective in diminishing the negative cognitive
effects of epilepsy surgery.19,40
However, there is no clear consensus regarding the best time interval for evaluating
neuro-cognitive function after epilepsy surgery to detect any impairments that may
exist so that such patients may be expeditiously directed toward the appropriate
cognitive rehabilitation therapy. Therefore, the aim of our study is to compare and
contrast the pre-operative neuropsychological profile in patients undergoing ATL
for epilepsy with immediate postoperative and early post-operative (at 3 months)
25
performance. We hypothesized that short-term evaluation beginning at six weeks
after resective epilepsy surgery would reveal early changes in neuro-cognitive
function that may help to identify patients who may need expeditious referral to
rehabilitation, which may ultimately influence decisions such as early return to
work or school.
26
3. AIMS & OBJECTIVES
The aim of our study is
1) To compare and contrast the pre-operative neuro-psychological profile in
patients undergoing ATL(Left + Right) for epilepsy with immediate postoperative
and early post-operative (at 3 months) performance.
2) To compare the neuro-psychological profile in the immediate postoperative
period and early postoperative period between patients who have undergone Right
ATL vs. patients who have undergone Left ATL.
27
4. MATERIALS & METHODS:
This is a prospective non-randomized observational study conducted at the
Department of Neurosurgery and Madhavan Nayar Center for Comprehensive
Epilepsy Care (RMNC), Sree Chitra Tirunal Institute for Medical Sciences &
Technology from June 2015 to August 2016. The Institutional Ethics Committee of
the Sree Chitra Tirunal Institute for Medical Sciences & Technology approved this
study and signed informed consent was obtained from all patients for inclusion.
Relevant data was de-identified for use in statistical analyses.
Twenty patients treated at our institute were considered for inclusion in this study.
The Inclusion Criteria were pre-defined as -
i) Medically refractory epilepsy of temporal origin with imaging features
suggestive of mesial temporal sclerosis and electro-clinical concordance
ii) Adults >18 years
iii) Normal vision and hearing pre-operatively
Patients with extra-temporal lobe epilepsy, defective vision and hearing, with IQ of
< 40, with h/o previous temporal lobe surgery and with post traumatic epilepsy
28
were excluded from this study. Patients considered for selective mesial temporal
lobe surgery were also excluded from this study.
All patients included in the study underwent a standard anterior temporal
lobectomy along with amygdalo-hippocampectomy (amygdala + anterior third of
hippocampus). The extent of resection of temporal neocortical structures was
approximately around 3cm from the temporal pole in the dominant hemisphere and
around 4.5cm in the non-dominant hemisphere.
All patients included in the study underwent a detailed neuro-psychological
evaluation by a licensed neuro-psychologist with special emphasis on emotional
and musical cognitive abilities. The neuropsychological evaluation was conducted
at three different intervals – pre-operative (before surgery); immediate post-
operative (around 10 days after the surgery) and around 3 months after the surgery.
The neuro-psychological evaluation consisted of a battery of tests, broadly
surmised under the following headings.
(a) Intelligence test
(b) Tests for musical abilities
29
(c) Test for facial recognition
(d) Test for facial emotion recognition
(e) Test for emotional situation recognition
(f) Test for Auditory and Verbal memory Both Immediate Recall (IR)
(g) Test for Visual memory and Delayed Recall (DR)
Intelligence Test
Wechsler Adult Intelligence Scale (WAIS)
Wechsler test is one of the most frequently used measures in neuropsychological
batteries. The purpose of the Wechsler Scale is to provide a general measure of
intelligence function. It is a core instrument, giving information about the overall
level of intellectual functioning and the presence or absence of significant
intellectual ability, and providing clues to altered functions.
The Wechsler Adult intelligence scale – 4th ed India, is the Indian adaptation of the
global counterpart. It provides subtest and composite scores that represent
intellectual functioning in specific cognitive domains, as well as a composite score
that represent general intellectual ability. The test results are coded and a
composite IQ score is arrived at.
30
Test for musical ability:
To assess the musical ability of the examinee, we designed and subsequently
validated a new test battery. This idea is imported from Seashore Measures of
musical talents and modified appropriately. This newly developed battery contains
four sub tests as follows.
Pitch subtest: Twenty pairs of tones are presented to the examinee; in each pair the
participant determines whether the second tone is higher or lower in pitch than the
first. Number of correct responses indicates the score.
Loudness subtest: Nineteen pairs of tones are presented. The participant indicates
for each pair whether the second tone is stronger or weaker than the first. Number
of correct responses indicates the score.
Rhythm subtest: Fifteen pairs of rhythmic patterns comprise the rhythm test. The
participant indicates whether the two patterns in each pairs are same or different.
Number of correct responses indicates the score.
Timbre subtest: This test consist of fifteen pairs of tones. In each pair the
participant judges whether the tones are the same or different in tone quality.
Number of correct responses indicates the score.
31
Test for Facial recognition:
Facial recognition test is used to assess the ability of the subject to retain and
reproduce facial memory. In this test, the examinee is shown a series of
photographs of faces, one at a time and asked to remember each one. The
examinee is then shown a second series of photographs of faces, one at a time, and
asked to identify each faces as either one that he/she was shown previously or if it
is a new one. Number of correct responses indicates the score.
The aim of this test is to identify the ability of the examinee to interpret different
facial emotions. In this test Examinee is shown the pictures of faces depicting
universally accepted six different emotions (anger, fear, sad, surprise, disgust &
happy) and asked identify different emotions. Number of correct responses
indicates the score.
In this test the examinee is presented 20 different pictures that carry different
emotional situations (happiness, sadness, fear and anger) in an equal number of
distributions. The task is to correctly identify the emotional situation depicted in
Test for Facial Emotion Recognition:
Test for emotional situation recognition:
32
the pictures, with the help of corresponding smiles. The examinee is not making
verbal comments only pointing the corresponding smiles. Number of correct
responses indicates the score.
Test for Auditory and Verbal Memory:
Rey’s Auditory Verbal Learning and Memory Test:
This test assesses immediate memory span and elicits retroactive and proactive
interference tendencies and short term and long term retention. The test consists of
two 15- items word list, List A for learning trials and List B for distraction trials
and a 30-item word list for recognition trial. List A is presented 5 times, always in
the same order, with an assessment of recall of each presentation. Then, list B is
presented once and recall is recorded. After this the subject is asked to recall list- A
without presenting it. Twenty minutes after the recall of list A, the subject is asked
to recall the list A again without presenting it. After this, the word from the
recognition list are presented and the subject is asked to say “yes” for the word that
were present in List A and “no” for the words that were not presented in list A.
33
Test for Visual Memory:
Rey – Complex figure test:
The Complex Figure Test assesses the visuo-spatial memory and constructional
ability. The test consists of a complex stimulus figure. The subject is asked to copy
the stimulus figure without revealing the fact that he/she is supposed to recall the
figure after few minutes. The subject is asked to do free hand drawing, without
using a ruler to draw. The immediate recall trial is administered 3 minutes after the
copy trial is completed. The intermediate time between copy and recall, the subject
is given a verbal distraction task. Thirty minutes after the copy trial, the subject is
asked to once again draw the complex figure from memory for assessing the
delayed recall.
Statistical Analysis:
Descriptive and inferential statistical analysis has been carried out in the present
study. Results on continuous measurements are presented on Mean ± SD (Min-
Max) and results on categorical measurements are presented in Number (%).
Significance is assessed at 5 % level of significance.
Student t test (two tailed, dependent) has been used to find the significance of
study parameters on continuous scale within each group.
34
Significant figures
+ Suggestive significance (P value: 0.05<P<0.10)
* Moderately significant (P value: 0.01<P ≤ 0.05)
** Strongly significant (P value: P≤0.01)
Statistical software: The Statistical software namely SAS 9.2, SPSS 15.0, Stata
10.1, MedCalc 9.0.1 , Systat 12.0 and R environment ver. 2.11.1 were used for
the analysis of the data.
5. OBSERVATIONS &
A total of 20 patients (12 male and
Lobectomy (ATL) at the Department of Neurosurgery,
for Medical Sciences & Technology between June 2015
were divided into groups according to
underwent left ATL, and nine patients (45%) underwent righ
Side
Left
Right
Total
OBSERVATIONS & RESULTS:
total of 20 patients (12 male and 8 female) underwent Anterior Temporal
Department of Neurosurgery, Sree Chitra Tirunal Institute
Technology between June 2015 - August 2016
according to the side of surgery. Eleven pat
derwent left ATL, and nine patients (45%) underwent right ATL.
Side No. of patients %
Left 11 55.0
Right 9 45.0
Total 20 100.0
55%
45%
Side
Left
Right
35
) underwent Anterior Temporal
Sree Chitra Tirunal Institute
August 2016. Patients
side of surgery. Eleven patients (55%)
Outcomes of the Neuro-psychological battery of tests
Intelligence Quotient (IQ):
In our study, as a whole, of the
the average IQ pre-operatively
operative period was 64.90
post-operatively was 68.20.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post
IQ 61.70
(±22.42)
64.90
(±28.04)
68.20
(±28.59)
Preop
IQ 61.7
58
60
62
64
66
68
70
psychological battery of tests:
of the 20 patients who underwent ATL (left
eratively was 61.70. The mean IQ in the immediate post
64.90 and the average IQ during follow-up in the 3
mon.
post-op
Difference p
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
68.20
(±28.59)
+ 3.2 + 6.5 + 3.3 0.236
Preop Imm Post op 3rd month Postop
61.7 64.9 68.2
Mean IQ
36
L (left + right ATL),
The mean IQ in the immediate post-
up in the 3rd
month
p – Value
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
0.013 * 0.075 +
37
As compared to the pre-op values the mean IQ showed an increase of 3.2 (p value
= 0.236) in the immediate post-op period and in the 3rd
month post-op there was an
increase in mean IQ of 6.5 (p value = 0.013*) as compared to pre-op values. The
mean IQ showed an increase of 3.3 (p value = 0.075+) when the immediate post-op
values were compared to the 3rd
month post-op values.
The increase in IQ between pre-op to 3rd
month post-op was found statistically
significant (p value < 0.05). The increase in IQ between immediate post-op to 3rd
month post-op was found to be suggestive of significance statistically (p value <
0.10).
IQ change in Left ATL vs. Right ATL:
On evaluating the mean IQ levels in patients who underwent left ATL (n=11),
there was an increase in mean IQ of 8.0 (p value = 0.070+) in the 3
rd month post-op
period as compared to pre-op values. The mean IQ showed an increase of 6.27 (p
value = 0.031*) when the immediate post-op values were compared to the 3rd
month post-op values.
Among patients who underwent right ATL (n=9), there was an increase of mean
IQ values by 5.0 (p value = 0.057 +) in the immediate post-op period and in the 3
rd
month post-op there was an increase in mean IQ of 4.67 (p value = 0.078+) as
compared to pre-op values.
38
IQ
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL
55.36
(±20.79) 57.09
(±27.76)
63.36
(±29.45) + 1.727 + 8.000 + 6.273 0.706 0.070
+ 0.031*
Right
ATL 69.44
(±23.05)
74.44
(±26.79)
74.11
(±28.03) + 5.000 + 4.667 - 0.333 0.057
+ 0.078
+ 0.864
Hence it was found in our study that patients undergoing Left ATL had significant
improvement in the post-op IQ values(p value <0.05) at 3 months while patients
undergoing Right ATL had only a modest improvement of IQ in the post op period
(p value < 0.10).
Pre Op Imm Post Op 3rd month Post Op
Left ATL 55.36 57.09 63.36
Right ATL 69.44 74.44 74.11
40
50
60
70
80
90
Mean IQ : Left vs Right ATL
Test for Musical Ability – Pitch Recognition Subtest
In our study, the average pitch recognition score
mean pitch recognition score
during follow-up in the 3rd
score was 11.15.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post
Pitch 11.05
(± 3.05)
11.40
(± 2.87)
11.15
(± 2.62
As compared to the pre-op values the
increase of 0.35 (p value = 0.548
month post-op there was an increase
value = 0.869) as compared to pre
Preop
Pitch 11.05
10
10.5
11
11.5
12
Pitch Recognition Subtest
In our study, the average pitch recognition score pre-operatively was
pitch recognition score in the immediate post-operative period was
rd month post-operatively the mean pitch recognition
mon.
post-op
Difference p
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
11.15
(± 2.62)
+ 0.35 + 0.10 - 0.25 0.548
op values the mean pitch recognition scores showed an
= 0.548) in the immediate post-op period and in the 3
there was an increase in mean pitch recognition scores
as compared to pre-op values.
Preop Imm Post op 3rd month Postop
11.05 11.4 11.15
Pitch Score
39
operatively was 11.05. The
operative period was 11.40 and
the mean pitch recognition
p – Value
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
0.869 0.685
pitch recognition scores showed an
op period and in the 3rd
in mean pitch recognition scores of 0.1 (p
3rd month Postop
40
The change in the pitch recognition scores between pre-op values and immediate
post-op values and 3rd
month post-op values were not found to be statistically
significant (p value > 0.10).
Pitch recognition score change in Left ATL vs. Right ATL:
On evaluating the mean pitch recognition scores in patients who underwent Left
ATL (n=11), there was an increase of 0.27 (p value = 0.720) in the immediate post-
op period and in the 3rd
month post-op, there was a decrease in the mean pitch
recognition scores of 0.27 (p value = 0.743) as compared to pre-op values. The
mean pitch recognition scores showed a decrease of 0.54 (p value = 0.493) when
the immediate post-op values were compared to the 3rd
month post-op values.
Among patients who underwent right ATL (n=9), there was an increase of mean
pitch recognition scores by 0.44 (p value = 0.650) in the immediate post-op period
and in the 3rd
month post-op, there was an increase in the mean pitch recognition of
0.55 (p value = 0.560) as compared to pre-op values. The mean pitch recognition
scores showed a slight increase of 0.11 (p value = 0.915) when the immediate post-
op values were compared to the 3rd
month post-op values.
41
Pitch
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 12.00
(±2.90)
12.27
(±3.13)
11.73
(±1.85) +0.273 -0.273 -0.545 0.720 0.743 0.493
Right
ATL 9.89
(±2.98)
10.33
(±2.24)
10.44
(±3.32) +0.444 +0.556 +0.111 0.650 0.560 0.915
The change in the pitch recognition scores between pre-op values and immediate
post-op values and 3rd
month post-op values in patients undergoing Left ATL vs.
Right ATL was not found to be statistically significant (p value > 0.10).
Test for Musical Ability – Rhythm Recognition Subtest
In our study, the average rhythm recognition score pre-operatively was 14.20. The
mean rhythm recognition score in the immediate post-operative period was 13.80
Preop Imm Post op 3rd month Postop
Left ATL 12 12.27 11.73
Right ATL 9.89 10.33 10.44
8
9
10
11
12
13
14
Mean Pitch Score : Left vs Right ATL
and during follow-up in the 3
score was 13.40.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post
Rhythm 14.20
(±1.58)
13.80
(±1.67)
13.40
(±1.93)
As compared to the pre-op values the
decrease of 0.40 (p value = 0.379
month post-op, there was a de
value = 0.061+) as compared to pre
Rhythm
12.5
13
13.5
14
14.5
15
up in the 3rd
month post-operatively the mean pitch recognition
mon.
post-op
Difference p
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
13.40
(±1.93) 0.400 0.800 0.400 0.379
op values the mean rhythm recognition scores showed a
= 0.379) in the immediate post-op period and
, there was a decrease in mean rhythm recognition scores
as compared to pre-op values.
Preop Imm Post op 3rd month Postop
14.2 13.8 13.4
Rhythm Score
42
the mean pitch recognition
p – Value
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
0.061+ 0.278
mean rhythm recognition scores showed a
period and in the 3rd
in mean rhythm recognition scores of 0.80 (p
3rd month Postop
43
The change in the rhythm recognition scores between pre-op values and 3rd
month
post-op values were suggestive of significance statistically (p value < 0.1).
Rhythm recognition score change in Left ATL vs. Right ATL:
On evaluating the mean rhythm recognition scores in patients who underwent left
ATL (n=11), there was a decrease of 0.72 (p value = 0.16) in the immediate post-
op period and in the 3rd
month post-op, there was a decrease in the mean rhythm
recognition scores of 1.45 (p value = 0.020*) as compared to pre-op values.
Among patients who underwent right ATL (n=9), there was a decrease of mean
rhythm recognition scores by 0.20 (p value = 0.780) in the immediate post-op
period and in the 3rd
month post-op, there was an increase in the mean rhythm
recognition values of 0.02 (p value = 0.960) as compared to pre-op values.
Rhythm
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 14.55
(±1.75)
13.82
(±1.66)
13.09
(±2.21) -0.727 -1.455 -0.727 0.167 0.020* 0.195
Right
ATL 13.78
(±1.30)
13.58
(±1.79)
13.80
(±1.56) -0.20 +0.002 +0.22 0.780 0.960 0.615
44
In our study, we found that in patients undergoing Left ATL, there was a
statistically significant (p value <0.05) fall in rhythm recognition scores between
pre-op and 3rd
month post op values. The change in the rhythm recognition scores
in patients undergoing Right ATL between pre-op, immediate post-op and 3rd
month post-op was not found to be statistically significant.
Test for Musical Ability – Timbre Recognition Subtest
In our study, the average timbre recognition score pre-operatively was 13.50. The
mean timbre recognition score in the immediate post-operative period was 13.50
and during follow-up in the 3rd
month post-operatively the mean timbre recognition
score was 13.30.
Preop Imm Post op 3rd month Postop
Left ATL 14.55 13.82 13.09
Right ATL 13.78 13.58 13.8
12
12.5
13
13.5
14
14.5
15
Mean Rhythm Score : Left vs Right ATL
Variable
Pre-op
Imm.
post-op
3rd
mon.
post
Timbre 13.50
(±1.64)
13.50
(±1.61)
13.30
(±1.38)
As compared to the pre-op values the
change in the immediate post
decrease in mean timbre recognition scores
pre-op values.
The change in the timbre recognition scores between pre
post-op values and 3rd
month post
significant (p value > 0.10).
Timbre
12.5
13
13.5
14
14.5
mon.
post-op
Difference p
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
13.30
(±1.38) 0.000 -0.200 -0.200 1.000
op values the mean timbre recognition scores showed no
post-op period and in the 3rd
month post-op
in mean timbre recognition scores of 0.2 (p value = 0.869) as compared to
recognition scores between pre-op values and immediate
month post-op values were not found to be statistically
Preop Imm Post op 3rd month Postop
13.5 13.5 13.3
Mean Timbre Score
45
p – Value
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
0.645 0.606
mean timbre recognition scores showed no
op there was a
as compared to
op values and immediate
op values were not found to be statistically
3rd month Postop
46
Timbre recognition score change in Left ATL vs. Right ATL:
On evaluating the mean timbre recognition scores in patients who underwent Left
ATL (n=11), there was a decrease of 0.45 (p value = 0.395) in the immediate post-
op period and in the 3rd
month post-op, there was a decrease in the mean timbre
recognition scores of 0.909 (p value = 0.074+) as compared to pre-op values.
Among patients who underwent Right ATL (n=9), there was an increase of mean
timbre recognition scores by 0.55 (p value = 0.302) in the immediate post-op
period and in the 3rd
month post-op, there was an increase in the mean timbre
recognition of 0.66 (p value = 0.360) as compared to pre-op values.
Timbre
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 13.73
(±0.90)
13.27
(±1.90)
12.82
(±1.66) -0.455 -0.909 -0.455 0.395 0.074+ 0.501
Right
ATL 13.22
(±2.28)
13.78
(±1.20)
13.89
(±0.60) +0.556 +0.667 +0.111 0.302 0.360 0.729
In our study, we found that in patients undergoing Left ATL, there was a fall of
timbre recognition scores between pre-op and 3rd
month post-op values which was
suggestive of significance statistically (p value <0.10). The change in the timbre
recognition scores in patients undergoing Right ATL between pre-op, immediate
47
post-op and 3rd
month post-op was not found to be statistically significant (p value
> 0.10.
Test for Musical Ability – Loudness Recognition Subtest:
In our study, the average loudness recognition score pre-operatively was 18.05.
The mean loudness recognition score in the immediate post-operative period was
17.45 and during follow-up in the 3rd
month post-operatively the mean loudness
recognition score was 18.15.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Loudness 18.05
(±1.70)
17.45
(±2.33)
18.15
(±1.39) -0.600 +0.100 +0.700 0.293 0.821 0.217
Preop Imm Post op 3rd month Postop
Left ATL 13.73 13.27 12.82
Right ATL 13.22 13.78 13.89
12
12.5
13
13.5
14
14.5
15
Mean Timbre Score : Left vs Right ATL
As compared to the pre-op values the
decrease of 0.6 (p value = 0.293)
month post-op there was an in
value = 0.821) as compared to pre
The change in the loudness
immediate post-op values and 3
statistically significant (p value > 0.10).
Loudness recognition score
On evaluating the mean loudness
Left ATL (n=11), there was a
post-op period and in the 3
Loudness
16
16.5
17
17.5
18
18.5
19
Mean Loudness Score
op values the mean loudness recognition scores showed a
rease of 0.6 (p value = 0.293) in the immediate post-op period
there was an increase in mean loudness recognition scores
as compared to pre-op values.
ange in the loudness recognition scores between pre-op values and
op values and 3rd
month post-op values were not found to be
statistically significant (p value > 0.10).
recognition score change in Left ATL vs. Right ATL:
evaluating the mean loudness recognition scores in patients who underwent
eft ATL (n=11), there was a decrease of 1.63 (p value = 0.03*) in the immediate
and in the 3rd
month post-op, there was a decrease
Preop Imm Post op 3rd month Postop
18.05 17.45 18.15
Mean Loudness Score
48
mean loudness recognition scores showed a
op period and in the 3rd
in mean loudness recognition scores of 0.1 (p
op values and
op values were not found to be
recognition scores in patients who underwent
in the immediate
crease in the mean
3rd month Postop
49
loudness recognition scores of 0.18 (p value = 0.64) as compared to pre-op values.
Among patients who underwent right ATL (n=9), there was an increase of mean
loudness recognition scores by 0.67 (p value = 0.397) in the immediate post-op
period and in the 3rd
month post-op, there was an increase in the mean loudness
recognition of 0.44 (p value = 0.622) as compared to pre-op values.
Loudness
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left ATL 18.18
(±1.47)
16.55
(±2.62)
18.00
(±1.41) -1.636 -0.182 +1.455 0.036* 0.640 0.120
Right
ATL 17.89
(±2.03)
18.56
(±1.33)
18.33
(±1.41) +0.667 +0.444 -0.222 0.397 0.622 0.681
Preop Imm Post op 3rd month Postop
Left ATL 18.18 16.55 18
Right ATL 17.89 18.56 18.33
16
16.5
17
17.5
18
18.5
19
Mean Loudness Score : Left vs Right ATL
50
In our study, we found that in patients undergoing Left ATL, there was a fall of
loudness recognition scores between pre-op and immediate post-op values which
was statistically significant (p value <0.05). However the loudness recognition
score returned to near pre-op baseline value in the 3rd
month post-op follow-up.
The change in the loudness recognition scores in patients undergoing Right ATL
between pre-op, immediate post-op and 3rd
month post-op were not found to be
statistically significant (p value > 0.10).
Facial Recognition:
In our study, the average facial recognition score pre-operatively was 33.5. The
mean facial recognition score in the immediate post-operative period was 35.75
and during follow-up in the 3rd
month post-operatively the mean facial recognition
score was 36.50.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Facial
Recogn
33.55
(±5.08)
35.75
(±4.55)
36.50
(±5.39) +2.200 +2.950 +0.750 0.051+ 0.007** 0.428
As compared to the pre-op values the mean facial recognition scores showed an
increase of 2.2 (p value = 0.051+) in the immediate post-op period and in the 3
rd
month post-op there was an in
value = 0.007**) as compared to pre
The change in the facial recognition scores between pre
post-op values was suggestive of significance
in the facial recognition scores between pre
was found to be strongly significant statistically (p value <
Facial recognition score change in Left ATL
On evaluating the mean facial recognition scores in patients who underwent Left
ATL (n=11), there was an in
op period and in the 3rd
month post
recognition scores of 3.0 (p value
Facial Recognition
33.5
34.5
35.5
36.5
Facial Recognition Score
there was an increase in mean facial recognition scores
as compared to pre-op values.
The change in the facial recognition scores between pre-op values and immediate
was suggestive of significance(p value < 0.10), whereas the change
in the facial recognition scores between pre-op values and 3rd
month post
was found to be strongly significant statistically (p value < 0.01).
change in Left ATL vs. Right ATL:
On evaluating the mean facial recognition scores in patients who underwent Left
n increase of 1.36 (p value =0.34) in the immediate
month post-op, there was an increase in the mean facial
(p value = 0.074+) as compared to pre-op values
Preop Imm Post op3rd month
Postop
Facial Recognition 33.55 35.75 36.5
33
33.5
34
34.5
35
35.5
36
36.5
37
Facial Recognition Score
51
recognition scores of 2.95 (p
and immediate
, whereas the change
month post-op values
On evaluating the mean facial recognition scores in patients who underwent Left
in the immediate post-
in the mean facial
op values.
52
Among patients who underwent right ATL (n=9), there was an increase of mean
facial recognition scores by 3.2 (p value = 0.089+) in the immediate post-op period
and in the 3rd
month post-op, there was an increase in the mean facial recognition
of 2.8(p value = 0.048*) as compared to pre-op values.
Facial
Recogn
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 33.55
(±4.7)
34.91
(±4.04)
36.55
(±5.97) +1.364 +3.000 +1.636 0.343 0.074+ 0.143
Right
ATL 33.56
(±5.81)
36.78
(±5.17)
36.44
(±4.93) +3.222 +2.889 -0.333 0.089+ 0.048* 0.843
In our study, we found that in patients undergoing Left ATL, the increase in facial
recognition scores between pre-op and 3rd
month post-op was suggestive of
Preop Imm Post op 3rd month Postop
Left ATL 33.55 34.91 36.55
Right ATL 33.56 36.78 36.44
33
33.5
34
34.5
35
35.5
36
36.5
37
Facial Recognition Score : Left vs Right ATL
53
significance statistically (p value <0.10). The increment in the facial recognition
scores in patients undergoing Right ATL between pre-op to immediate post-op was
suggestive of significance statistically (p value <0.10) while the increase in scores
between pre-op and 3rd
month post-op was found to be statistically significant
(<0.05).
Facial Emotion Recognition:
In our study, the average facial emotion recognition score pre-operatively was
5.25. The mean facial emotion recognition score in the immediate post-operative
period was 4.80 and during follow-up in the 3rd
month post-operatively it was 4.85.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Facial
Emotion
Recogn
5.25
(±1.07)
4.80
(±1.67)
4.85
(±1.46) -0.450 -0.400 +0.050 0.176 0.104 0.883
As compared to the pre-op values the mean facial emotion recognition scores
showed a decrease of 0.45 (p value = 0.17) in the immediate post-op period and
in the 3rd
month post-op there was a decrease in mean facial emotion recognition
scores of 0.40 (p value = 0.104) as compared to pre-op values.
The change in the facial emotion recognition scores between pre
immediate post-op values and 3
statistically significant (p value > 0.10).
Facial emotion recognition score
On evaluating the mean facial emotion recognition scores in patients who
underwent Left ATL (n=11), there was a de
immediate post-op period and in the 3
mean facial emotion recognition scores of
pre-op values.
Among patients who underwent right ATL (n=9), there was
facial emotion recognition scores by
Facial emoticon
recognition
4
4.5
5
5.5
6
Facial Emotion Recognition Score
The change in the facial emotion recognition scores between pre-
op values and 3rd
month post-op values were not found to be
statistically significant (p value > 0.10).
recognition score change in Left ATL vs. Right ATL:
On evaluating the mean facial emotion recognition scores in patients who
underwent Left ATL (n=11), there was a decrease of 0.72 (p value
and in the 3rd
month post-op, there was a de
mean facial emotion recognition scores of 0.18 (p value = 0.50) as compared to
Among patients who underwent right ATL (n=9), there was a decrease of
facial emotion recognition scores by 0.11(p value = 0.81) in the immediate
Preop Imm Post op3rd month
Postop
Facial emoticon
recognition5.25 4.8 4.85
4
4.5
5
5.5
6
Facial Emotion Recognition Score
54
-op values and
op values were not found to be
Right ATL:
On evaluating the mean facial emotion recognition scores in patients who
= 0.13) in the
there was a decrease in the
as compared to
crease of mean
in the immediate post-op
55
period and in the 3rd
month post-op, there was a decrease in the mean facial
emotion recognition of 0.67 (p value = 0.14) as compared to pre-op values.
Facial
Emotion
Recogn
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 5.18
(±1.17)
4.45
(±2.02)
5.00
(±1.55) -0.727 -0.182 +0.545 0.136 0.506 0.052+
Right
ATL 5.33
(±1.00)
5.22
(±1.09)
4.67
(±1.41) -0.111 -0.667 -0.556 0.813 0.141 0.416
In our study, we found that in patients undergoing both Left ATL and Right ATL,
the change in the facial emotion recognition scores were not found to be
statistically significant.
Preop Imm Post op 3rd month Postop
Left ATL 5.18 4.45 5
Right ATL 5.33 5.22 4.67
4
4.5
5
5.5
6
Facial Emotion Recognition Score : Left vs Right ATL
56
Emotion Situation Recognition:
In our study, the average emotion situation recognition score pre-operatively was
17.5. The mean emotion situation recognition score in the immediate post-
operative period was 17.85 and during follow-up in the 3rd
month post-operatively
the mean emotion situation recognition score was 18.85.
Variable
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Emotion
Situtn
Recogn
17.50
(±3.00)
17.85
(±3.00)
18.85
(±1.81) +0.350 +1.350 +1.000 0.569 0.007** 0.035*
As compared to the pre-op values the mean emotion situation recognition scores
showed an increase of 0.35 (p value = 0.56) in the immediate post-op period and in
the 3rd
month post-op there was an increase in mean emotion situation recognition
scores of 1.35 (p value = 0.0.007**) as compared to pre-op values. There was an
increase of 1.0 in the 3rd
month post-op scores as compared to immediate post-op
The increase in the emotion situation recognition scores between pre-op values and
3rd
month post-op values was found to be strongly significant statistically (p value
< 0.01), while the increase in the emotion situation recognition scores between
values (p value = 0.035*)
immediate post-op values and 3
moderately significant statistically
Emotion situation recognition score
On evaluating the mean emotion situation recognition scores in patients who
underwent Left ATL (n=11), there was a
0.87) in the immediate post
increase in the mean emotion situation recognition scores
0.014*) as compared to pre
scores showed an increase of 1.27
values were compared to 3rd
Among patients who underwent right ATL (n=9), there was
emotion situation recognition scores by
Emotional situation
recognition
17
17.5
18
18.5
19
19.5
Emotion Situation Recognition Score
op values and 3rd
month post-op values was foun
statistically (p value < 0.05).
recognition score change in Left ATL vs. Right ATL:
On evaluating the mean emotion situation recognition scores in patients who
underwent Left ATL (n=11), there was a marginal decrease of 0.091
post-op period and in the 3rd
month post-op,
in the mean emotion situation recognition scores of 1.18
compared to pre-op values. The mean emotion situation recognition
of 1.27 (p value = 0.040*) when the immediate post
to 3rd month post-op.
Among patients who underwent right ATL (n=9), there was an increase of
n recognition scores by 0.89 (p value = 0.45) in the immediate
Preop Imm Post op 3rd month Postop
17.5 17.85 18.85
Emotion Situation Recognition Score
57
op values was found to be
Right ATL:
On evaluating the mean emotion situation recognition scores in patients who
0.091 (p value =
op, there was an
of 1.18 (p value =
. The mean emotion situation recognition
) when the immediate post-op
an increase of mean
in the immediate
3rd month Postop
18.85
58
post-op period and in the 3rd
month post-op, there was an increase in the mean
emotion situation recognition of 1.5 (p value = 0.116) as compared to pre-op
values.
Emotion
Situtn
Recogn
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 17.73
(±2.65)
17.64
(±3.50)
18.91
(±2.17) -0.091 +1.182 +1.273 0.887 0.014* 0.040*
Right
ATL 17.22
(±3.53)
18.11
(±2.42)
18.78
(±1.39) +0.889 +1.556 +0.667 0.452 0.116 0.397
In our study, we found that in patients undergoing Left ATL, there was an increase
in the emotion situation recognition scores between pre-op and 3rd
month post-op
values and a similar increase between immediate post-op and 3rd
month post-op
values which was statistically significant (p value <0.05). The change in the
Preop Imm Post op 3rd month Postop
Left ATL 17.73 17.64 18.91
Right ATL 17.22 18.11 18.78
17
17.5
18
18.5
19
19.5
Emotion Situation Recognition Score : Left vs Right ATL
59
emotion situation recognition scores in patients undergoing Right ATL between
pre-op, immediate post-op and 3rd
month post-op were not found to be statistically
significant (p value > 0.10).
Auditory and Verbal Memory:
In our study, the average auditory and verbal memory score on immediate recall
(IR) pre-operatively was 8.95. The mean auditory and verbal memory score (IR) in
the immediate post-operative period was 8.65 and during follow-up in the 3rd
month post-operatively it was 9.90.
The average auditory and verbal memory score on delayed recall (DR) pre-
operatively was 8.65. The mean auditory and verbal memory score (DR) in the
immediate post-operative period was 8.50 and during follow-up in the 3rd
month
post-operatively it was 10.10.
Auditory
&
Verbal
Memory
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
IR 8.95
(±3.35)
8.65
(±4.31)
9.90
(±3.88) 0.300 -0.950 -1.250 0.639 0.033* 0.056+
DR 8.65
(±3.38)
8.50
(±4.61)
10.10
(±3.40) 0.150 -1.450 -1.600 0.851 0.024* 0.058+
As compared to the pre-op values the
(IR) showed an increase of 0.95 (p value = 0.03*) in the 3
There was an increase of 1.25 (p value = 0.056
Preop
AVL DR 8.65
8
8.5
9
9.5
10
10.5
Auditory & Verbal Memory: Delayed Recall
Preop
AVL IR 8.95
8
8.5
9
9.5
10
10.5
Auditory & Verbal Memory: Immediate Recall
compared to immediate post
op values the mean auditory and verbal memory scores
(IR) showed an increase of 0.95 (p value = 0.03*) in the 3rd
month post
There was an increase of 1.25 (p value = 0.056+) in the 3
rd month post
Preop Imm Post op 3rd month Postop
8.65 8.5 10.1
Auditory & Verbal Memory: Delayed Recall
Preop Imm Post op 3rd month Postop
8.65 9.9
Auditory & Verbal Memory: Immediate Recall
compared to immediate post-op scores.
60
mean auditory and verbal memory scores
post-op period.
month post-op scores as
3rd month Postop
10.1
Auditory & Verbal Memory: Delayed Recall
3rd month Postop
9.9
Auditory & Verbal Memory: Immediate Recall
61
When compared with the pre-op values the mean auditory and verbal memory
scores (DR) showed an increase of 1.45 (p value = 0.024*) in the 3rd
month post-op
period. There was an increase of 1.60 (p value = 0.058+) in the 3
rd month post-op
scores as compared to immediate post-op scores.
The improvement in auditory and verbal memory for both immediate recall and
delayed recall between pre-op values and 3rd
month post-op values was found to be
statistically significant (p value < 0.05), while the increase in the auditory and
verbal memory scores for both immediate and delayed recall between immediate
post-op values and 3rd
month post-op values was found to be suggestive of
statistical significance (p value < 0.10).
Auditory and Verbal Memory change in left ATL vs. Right ATL:
On evaluating the average auditory and verbal memory scores (both IR+DR) in
patients who underwent Left ATL (n=11), there was a decrease of 1.9 (p value =
0.02*) in the immediate post-op period and in the 3rd
month post-op, these values
reached almost pre-op values with a marginal difference of 0.45 (p value = 0.5).
Among patients who underwent Right ATL (n=9), there was an increase of the
average auditory and verbal memory scores (both IR+DR) by 1.4 (p value = 0.05*)
62
in the immediate post-op period and in the 3rd
month post-op, there was an increase
of 1.5 (p value = 0.028*) as compared to pre-op values.
Auditory
&
Verbal
Memory
(IR+DR)
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 11.55
(±2.25)
9.64
(±3.35)
11.09
(±2.81) 1.909 0.455 -1.455 0.028* 0.567 0.058+
Right
ATL 10.56
(±3.28)
12.00
(±3.67)
12.33
(±2.69) -1.444 -1.778 -0.333 0.050+ 0.028* 0.700
In our study, we found that in patients undergoing Left ATL, there was a fall of
Auditory and Verbal Memory in the immediate post-op period (p value < 0.05)
which gradually improved and reached almost pre-op baseline levels by the 3rd
Preop Imm Post op 3rd month Postop
Left ATL 11.55 9.64 11.09
Right ATL 10.56 12 12.33
9
10
11
12
13
Auditory & Verbal Memory: Left vs Right ATL
63
month post-op follow-up. In patients undergoing Right ATL, the Auditory and
verbal memory scores improved in the immediate post-op period as well as in the
3rd
month post op both of which were statistically significant (p value < 0.05).
Visual Memory:
In our study, the visual memory score on immediate recall (IR) pre-operatively was
14.13. The mean visual memory score (IR) in the immediate post-operative period
was 19.0 and during follow-up in the 3rd
month post-operatively it was 22.5.
The average visual memory score on delayed recall (DR) pre-operatively was
14.15. The mean visual memory score (DR) in the immediate post-operative period
was 18.28 and during follow-up in the 3rd
month post-operatively it was 20.58.
Visual
Memory
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
IR 14.13
(±8.39)
19.00
(±7.79)
22.58
(±7.32) +4.875 +8.450 +3.575 0.004** <0.001** 0.007**
DR 14.15
(±8.94)
18.28
(±8.16)
20.58
(±9.02) +4.125 +6.425 +2.300 0.017* <0.001** 0.137
As compared to the pre-op values the mean visual memory scores (IR) showed an
increase of 4.8 (p value = 0.004**) in the immediate post-op period and in the 3rd
month post-op period there was an increase of 8.45 (p value < 0.001**).
As compared to the pre-op values the
increase of 4.12 (p value = 0.017*) in the immediate post
month post-op period there was an increase of 6.42 (p value < 0.001**).
Visual Memory IR
13
14
15
16
17
18
19
20
21
22
23
Visual Memory: Immediate Recall
Visual Memory DR
13
14
15
16
17
18
19
20
21
Visual Memory: Delayed Recall
op values the mean visual memory scores (DR) showed an
increase of 4.12 (p value = 0.017*) in the immediate post-op period and in the 3
there was an increase of 6.42 (p value < 0.001**).
Preop Imm Post op 3rd month Postop
14.13 19 22.58
Visual Memory: Immediate Recall
Preop Imm Post op 3rd month Postop
14.15 18.28 20.58
Visual Memory: Delayed Recall
64
mean visual memory scores (DR) showed an
op period and in the 3rd
there was an increase of 6.42 (p value < 0.001**).
3rd month Postop
22.58
3rd month Postop
20.58
65
The improvement in visual memory for both immediate recall and delayed recall
between pre-op and immediate post-op period was significant statistically (p <
0.05) whereas the increase in visual memory scores between pre-op values and 3rd
month post-op values was found to be strongly significant statistically (p value <
0.01).
Visual Memory change in left ATL vs. Right ATL:
On evaluating the average visual memory scores (IR) in patients who underwent
Left ATL (n=11), there was an increase of 3.6 (p value = 0.093+) in the immediate
post-op period and in the 3rd
month post-op, these values further increased by 9.3
(p value = 0.003**). The mean visual memory scores (DR) in patients who
underwent Left ATL (n=11) showed an increase of 2.5 (p value = 0.271) in the
immediate post-op period and in the 3rd
month post-op, these values further
Among patients who underwent Right ATL (n=9), the average visual memory
scores (IR) showed an increase of 6.38 (p value = 0.02*) in the immediate post-op
period and in the 3rd
month post-op, these values further increased by 7.33 (p value
= 0.006**). The mean visual memory scores (DR) in patients who underwent
Right ATL (n=9) showed an increase of 6.0 (p value = 0.026*) in the immediate
increased by 7.63 (p value = 0.003**).
66
post-op period and in the 3rd
month post-op, these values showed an improvement
of 4.9 (p value = 0.024*).
Visual
Memory
(IR)
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 15.05
(±7.80)
18.68
(±6.5)
24.41
(±5.36) +3.636 +9.364 +5.727 0.093+ 0.003** 0.003**
Right
ATL 13.00
(±9.41)
19.39
(±9.55)
20.33
(±9.01) +6.389 +7.333 +0.944 0.023* 0.006** 0.572
Visual
Memory
(DR)
Pre-op
Imm.
post-op
3rd
mon.
post-op
Difference p – Value
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Pre-op
to
Imm.
post-op
Pre-op
to
3rd
mon.
post-op
Imm.
post-op
to
3rd
mon.
post-op
Left
ATL 15.55
(±8.36)
18.09
(±7.0)
23.18
(±5.40) +2.545 +7.636 +5.091 0.271 0.002** 0.011*
Right
ATL 12.44
(±9.82)
18.50
(±9.84)
17.39
(±11.66) +6.056 +4.944 -1.111 0.026* 0.024* 0.625
In our study, we found that in patients undergoing Left ATL (n=11), the visual
memory scores (IR) showed an improvement in the immediate post-op period that
was suggestive of significance (p value < 0.10). It was also noted that this
improvement in visual memory score (IR) further improved in the 3rd
month post-
op period which was strongly significant statistically (p value < 0.01).
In these patients with Left ATL (n=11), the visual memory scores (DR) showed
improvement in the 3rd
month post-op which was strongly significant statistically
(p value < 0.01).
67
Preop Imm Post op 3rd month Postop
Left ATL 15.05 18.68 24.41
Right ATL 13 19.39 20.33
11
12.5
14
15.5
17
18.5
20
21.5
23
24.5
Visual Memory Immediate Recall :
Left vs Right ATL
Preop Imm Post op 3rd month Postop
Left ATL 15.55 18.09 23.18
Right ATL 12.44 18.5 17.39
11
12.5
14
15.5
17
18.5
20
21.5
23
24.5
Visual Memory Delayed Recall :
Left vs Right ATL
68
Among patients undergoing Right ATL (n=9), the visual memory scores (IR)
showed an improvement in the immediate post-op period that was significant
statistically (p value < 0.05). It was also noted that this improvement in visual
memory score (IR) further improved in the 3rd
month post-op period which was
Among these patients with Right ATL (n=9), the visual memory scores (DR)
showed improvement, both in the immediate post-op period as well as in the 3rd
month post-op period which was significant statistically (p value < 0.05).
strongly significant statistically (p value < 0.01).
69
6. DISCUSSION
Literature is replete with evidence in abundance with regards to the neuro-
cognitive changes after epilepsy surgery. Despite this, ATL still continues to be the
most common surgical procedure performed worldwide for refractory temporal
lobe epilepsy.
In most of the studies that measure outcome after epilepsy surgery, the quality of
life profile and neuro-cognitive outcome are usually measured at 6 months to one
year post surgery. Long term follow-up of patients undergoing epilepsy surgery
has frequently shown that the neuro-cognitive deficits in most patients will
gradually improve over time and ultimately attain levels that are almost
comparable to pre-operative values.15,18
Knowledge of the timing of neuro-cognitive deficits after epilepsy surgery is
essential, as earlier intervention can potentially lessen the burden of such deficits
on a patient's quality of life. However, there is no clear consensus regarding the
best time interval for evaluating neuro-cognitive function after epilepsy surgery. In
our present study, the pre-operative neuropsychological profile in patients
undergoing Anterior Temporal Lobectomy (ATL) for epilepsy was compared with
immediate postoperative and early post-operative (at 3 months) performance to
evaluate the short term neuro-cognitive outcome after ATL.
70
Our study was a prospective non-randomized observational model in which 20
patients (12 male and 8 female) undergoing ATL and fulfilling the study inclusion
criteria were evaluated with a neuro-psychological battery of tests. The main aim
of the study was to assess the neuro-cognitive outcome after epilepsy surgery in the
short term (3 months post op) as well as to find any difference in neuro-cognitive
outcome between Left ATL vs. Right ATL.
In our study eleven patients (55%) underwent left ATL, and nine patients (45%)
underwent right ATL.
IQ outcome:
In our study, as a whole (Left + Right ATL), there was an increase in the IQ score
after ATL. The increase in IQ between pre-op to 3rd
month post-op was found
statistically significant (p value < 0.05) while the increase in IQ between
immediate post-op to 3rd
month post-op was found to be suggestive of significance
statistically (p value < 0.10).
It was also found in our study that patients undergoing Left ATL had significant
improvement in the post-op IQ values (p value <0.05) at 3 months while patients
undergoing Right ATL had only a modest improvement of IQ in the post op period
at 3 months follow-up (p value < 0.10). Hence our study shows that post ATL,
71
there is an improvement of IQ with patients undergoing Left ATL having a greater
increment in IQ post operatively as compared to patients with Right ATL.
These findings correlate with that of Lee et al.28
who found that 39% of patients in
their series had improvements in IQ. Our findings are also concordant with those
of Sherman et al.48
who reported in their series of 16 % improvement in IQ and
psychomotor speed.
The exact neuro-physiological basis for improvement in IQ is yet to be elucidated
but it has been postulated that improvement in IQ is a reflection of
reduction/elimination of seizures post-operatively. The improvement in IQ may
also be partly be explained by patients having a reduced intake of anti-epileptic
medications in the post-operative period, with literature replete with evidence of
obtunding effect of these medications on the neuro-cognitive functions.29,31
Outcome of tests for Musical ability:
In our study, the ability to appreciate music was assessed by evaluating 4
parameters viz. Pitch, Rhythm, Timbre & Loudness.
In our study, overall (Left + Right ATL) the change in the pitch, rhythm, timbre &
loudness recognition scores between pre-op values and immediate post-op values
and 3rd
month post-op values were not found to be statistically significant (p value
> 0.10).
72
However on further analysis, we found that there was a significant decrease (p
value < 0.05) in the rhythm, timbre and loudness recognition scores between pre-
op values and 3rd
month post-op values in patients who underwent Left ATL. The
change in the rhythm, timbre and loudness recognition scores in patients
undergoing Right ATL between pre-op, immediate post-op and 3rd
month post-op
was not found to be statistically significant (p value > 0.10).
Our study results indicate that, patients who undergo Left ATL have deficits in
musical abilities in the paradigm of appreciating the rhythm, timbre and loudness
of music. However the durability and persistence/improvement of such deficits
need long term follow-up evaluation to arrive at any definitive conclusions.
Our findings are similar to those of Hanschen et al.16
who had reported in their
study that the right hemisphere was involved in appreciation of gross attributes of
music and the left hemisphere was involved for appreciating certain attributes of
music like pitch and rhythm. In their report, Hanschen et al.16
had also revealed
impairment in rhythm discrimination, reading musical notation and detailed
musical analysis following left hemisphere damage.
73
Even though Kester et al.25
have reported that musical ability is predominantly a
function of the right temporal lobe, the possible explanation for the contrasting
findings in our study is that due to functional re-organization of the right
hemisphere in chronic epilepsy patients, the impact of right ATL may not be as
profound as expected on appreciation of musical abilities. However, due to
language lateralization to the left hemisphere, the impact of left ATL may be more
sensitive on musical attributes.
Impact of ATL on multimodal emotion perception:
Facial Recognition:
In our study, as a whole (Left + Right ATL), there was a marginal improvement in
facial recognition scores between pre-op values and immediate post-op values was
suggestive of significance (p value < 0.10). This improvement persisted into the 3rd
month post-op period where the change was found to be strongly significant
statistically (p value < 0.01).
When comparing the change in facial recognition in patients with Left vs. Right
ATL, in our study we found that, in patients undergoing Left ATL, the increase in
facial recognition scores between pre-op and 3rd
month post-op was only
marginally suggestive of significance statistically (p value <0.10). However the
74
increment in the facial recognition scores in patients undergoing Right ATL
between pre-op and 3rd
month post-op was found to be statistically significant
(<0.05).
The findings in our study are unique in the sense that we have reported an increase
in facial recognition after both Left and Right ATL. Previously Dulay et al.9
reported a minor improvement in facial recognition skills in patients with Left
ATL and a decline in facial recognition in patients with Right ATL.
We propose that facial recognition is in part aided by visual memory acumen,
which as our findings suggest is improved after ATL and will be subsequently
reviewed. We postulate that improvement in facial recognition is actually a
reflection of improvement in visual memory, with the proposed mechanism
discussed further on.
Facial Emotion Recognition:
In our study, we found that in patients undergoing both Left ATL and Right ATL,
the change in the facial emotion recognition scores were not found to be
statistically significant.
75
This finding has also been previously reported by Gosselin et al.14
who concluded
that facial emotion interpretation was most probably represented in a multimodal
fashion in both temporal lobes and hence resection of one temporal lobe is unlikely
to significantly affect the ability to decode facial emotions.
Emotion situation recognition:
In our study, we found that in patients undergoing Left ATL, there was an increase
in the emotion situation recognition scores between pre-op and 3rd
month post-op
values which was statistically significant (p value <0.05). The change in the
emotion situation recognition scores in patients undergoing Right ATL was not
found to be statistically significant (p value > 0.10).
These findings are similar to the ones reported by Dulay et al.9 and Gosselin et al.
14
who in their studies had reported a non-specific decline in general emotion
understanding. The findings in our study are unique in that till date no study has
emphasized on the paradigm of recognition of emotional situation. The validity of
this finding in the long term needs to be confirmed by prolonged follow-up of
patients.
76
Repercussions of ATL on memory:
Outcome on Auditory and Verbal Memory:
In our current study, considering both Left and Right ATL as a whole, it was found
that there was a significant improvement in auditory and verbal memory for both
immediate recall and delayed recall modes between pre-op values and 3rd
month
post-op values, which was found to be statistically significant (p value < 0.05). It
was also observed that there was a modest increase in the auditory and verbal
memory scores for both immediate and delayed recall modes between immediate
post-op values and 3rd
month post-op values was found to be suggestive of
statistical significance (p value < 0.10).
Verbal outcomes for both Left and Right ATL combined have to interpreted with
caution due to the fact that, Left ATL is traditionally known to negatively affect
verbal memory which may be negated by an improvement in the same by Right
ATL, when both the scores are considered together. In light of this, from our data
we found that ATL in general leads to a significant improvement in verbal
memory.
77
Our findings are in concurrence with those of Lee et al.28
who reported in their
study that there was an overall memory improvement after ATL by about 22%.
Baxendale et al.2
have also reported a modest improvement in memory of around
12% overall in patients undergoing ATL.
On further analysis of verbal memory outcomes in Left ATL vs. Right ATL, our
study revealed that in patients undergoing Left ATL, there was a significant fall of
Auditory and Verbal Memory in the immediate post-op period (p value < 0.05)
which gradually improved and reached almost pre-op baseline levels by the 3rd
month post-op follow-up. In patients undergoing Right ATL, the Auditory and
verbal memory scores improved in the immediate post-op period as well as in the
3rd
month post op both of which were statistically significant (p value < 0.05).
The findings from our study are in agreement with those of Lee et al.28
who
reported in their study that patients with Left ATL had a decline in verbal memory
and patients with Right ATL had a marginal improvement in verbal memory. Even
Sherman et al.48
in their meta-analysis reported a risk to verbal memory with left-
sided temporal surgery occurring in around 44% of patients.
78
Our study differs from previously published reports in that, patients undergoing
Left ATL do indeed have a decline in verbal memory, but our study also found
new evidence that such a decline of verbal memory after Left ATL rapidly
recovers in short term and reaches almost pre-op levels by the 3rd
month. This
finding is more significant in light of the fact that, even though Left ATL carries an
inherent risk of verbal memory deterioration as quoted by prior reports, our study
reveals that such a decline rapidly recovers in the post-op period.
Our study also reveals that patients undergoing Right ATL have a significant
improvement in their verbal memory. This finding again correlates well with
published reports like Baxendale et al.2 who noted in their large study of around
250 patients, of an improvement in verbal memory in patients with Right ATL by
almost around 47%.
Outcome on Visual Memory:
In our study, as a whole (Left ATL + Right ATL), there was an improvement in
visual memory for both immediate recall and delayed recall between pre-op and
immediate post-op period, which was significant statistically (p < 0.05). Also, there
we observed that there was an increase in visual memory scores between pre-op
values and 3rd
month post-op values was found to be strongly significant
statistically (p value < 0.01).
79
In our study, when the visual memory outcomes were compared between Left ATL
vs. Right ATL we found that in patients undergoing Left ATL, the visual memory
scores showed an improvement in the immediate post-op period that was
suggestive of significance (p value < 0.10) and this improvement continued well
into the 3rd
month post-op period, at which point of time the increment was
strongly significant statistically (p value < 0.01).
Among patients undergoing Right ATL, the visual memory scores showed an
improvement in the immediate post-op period that was significant statistically (p
value < 0.05). It was also noted that this improvement in visual memory further
improved into the 3rd
month post-op period, at which point of time it attained
strong significance statistically (p value < 0.01).
These findings of our study are similar to those of Sherman et al.48
who reported in
their meta-analysis of improvement in visual memory after Left ATL and transient
decline in visual memory in patients with Right ATL. Lee at al.28
, in their study
have previously reported an improvement of 26% for visual memory in patients
with Left ATL and a decline of 11% in patients with Right ATL.
80
Our study deviates from previously reported studies in literature, in that, we have
found an improvement of visual memory in patients with either Left or Right ATL.
Although the degree of improvement of visual memory is much more acute in
patients with Left ATL, patients with Right ATL also have shown increment in
visual memory scales. This is a new finding in our study in contrast to previously
reported studies wherein there was a reported decline in visual memory in patients
with Right ATL.
Theories abound as to the actual reason for why patients show improvement in
memory functions following ATL. First and foremost, it is generally agreed upon
that the epileptogenic foci or areas are non-functional or more aptly dysfunctional.
It is postulated that the mesial temporal structures undergo functional
reorganization after the onset of seizures, which maybe a predominant mechanism
for the preservation of function in patients with temporal lobe epilepsy. It has also
been found that in patients who show reorganization of memory function to areas
remote to the epileptic foci on f-MRI, the deficits of memory function in the post-
operative period are far fewer.4
81
These observations hint towards the probability that resection of the dysfunctional
neural areas that contribute to the pathogenesis of temporal lobe epilepsy also
indirectly removes the hurdles to memory function.42
It has also been postulated that anatomic localization of memory processing may
play a role in outcome after ATL. Patients showing activation of the ipsilateral
anterior mesial temporal structures during memory encoding tasks are more prone
to have deficits post-operatively, whereas those patients with predominant
posterior hippocampal activation or bilateral mesial temporal activity during
memory encoding are more likely to demonstrate improvement in the
postoperative period.3
Hence overall, from our study it is quite evident that ATL results in neuro-
cognitive changes, both benefit and deficit. Our study evaluated the neuro-
cognitive function at around 3 months postoperatively but the durability of the
findings arrived at is a question that remains unanswered. Our study results
emphasizes the importance of obtaining short term data in order to establish new
cognitive baselines that formulate the follow-up of such patients and also dictate
earlier and more effective interventions that can be put in place for better
rehabilitation of these patients.
82
7. CONCLUSION
The results of this study demonstrate that short-interval follow-up is effective in
elucidating cognitive changes following epilepsy surgery.
In some instances, this lends itself to the identification of patients who could
benefit from early intervention. In other cases, being able to identify the lack of
change, or even cognitive benefit, may influence decisions such as return to work
or school.
Furthermore, the results of this study show that epilepsy surgery is associated with
few cognitive deficits as well as benefits and over a long term epilepsy surgery is
still a safe procedure from the point of view of neuropsychological outcome.
83
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88
MASTER CHART
Case
No. Side
IQ Music
Pitch Rhythm Timbre Loudness
Pre-op
Imm.
Post
Op
3rd
month
post-op
Pre-op
Imm.
Post
Op
3rd
month
post-op
Pre-op
Imm
Post
Op
3rd
month
post-op
Pre-op
Imm
Post
Op
3rd
month
post-op
Pre-op
Imm
Post
Op
3rd
month
post-op
1 Left 82 98 99 14 17 13 15 15 15 13 14 15 19 15 19
2 Left 50 48 58 8 9 12 15 11 14 14 14 13 19 18 19
3 Left 80 92 109 16 18 15 15 15 15 14 14 13 19 19 16
4 Right 67 64 62 12 12 9 15 10 11 13 14 13 19 19 19
5 Right 47 55 48 6 10 10 13 15 13 14 14 14 13 19 19
6 Left 54 15 34 11 8 9 13 12 12 13 12 11 17 12 18
7 Right 92 105 107 10 9 10 15 15 15 15 14 14 19 19 15
8 Left 88 99 108 11 13 12 15 15 14 15 14 13 19 19 19
9 Left 35 42 47 9 9 13 13 15 14 13 13 14 15 15 17
10 Right 42 46 48 11 9 11 13 14 13 10 11 13 17 19 19
11 Left 38 45 42 17 12 13 15 14 14 14 15 14 19 18 19
12 Right 115 129 127 15 15 18 14 15 15 15 15 14 19 19 19
13 Left 52 54 57 11 13 11 18 15 13 14 15 12 19 19 19
14 Right 57 56 56 9 9 12 15 12 15 9 13 14 19 19 19
15 Left 21 29 25 9 11 10 11 11 7 12 11 9 16 15 15
16 Left 54 53 68 13 13 12 15 15 13 15 15 13 19 19 18
17 Left 55 53 50 13 12 9 15 14 13 14 9 14 19 13 19
18 Right 58 69 60 6 12 6 11 13 12 13 14 14 17 15 17
19 Right 67 64 67 8 8 10 14 15 15 15 14 14 19 19 19
20 Right 80 82 92 12 9 8 14 15 15 15 15 15 19 19 19
89
MASTER CHART
Case
No.
Facial Recognition Facial emotion recognition Emotional situation recognition
Pre-op Imm.
Post Op
3rd month
post-op Pre-op
Imm.
Post Op
3rd month
post-op Pre-op
Imm. Post
Op
3rd month
post-op
1 37 36 44 6 6 6 17 20 20
2 35 39 44 4 1 3 20 17 20
3 33 37 40 6 5 6 20 19 20
4 31 30 31 6 5 4 10 18 16
5 34 36 39 4 5 3 20 20 19
6 27 26 27 4 2 3 16 16 19
7 39 39 39 6 6 6 20 20 20
8 34 39 42 6 6 6 20 20 20
9 32 34 35 6 3 5 17 18 17
10 37 33 38 6 6 3 18 19 18
11 27 34 33 6 6 6 19 19 20
12 39 39 40 6 6 6 20 20 20
13 38 35 33 6 6 6 19 17 19
14 25 31 35 4 4 5 18 13 18
15 41 32 36 3 2 2 11 8 13
16 37 40 40 6 6 6 19 20 20
17 28 32 28 4 6 6 17 20 20
18 27 37 34 6 3 6 15 17 20
19 29 39 28 4 6 3 14 16 18
20 41 47 44 6 6 6 20 20 20
90
MASTER CHART
Case
No.
Auditory & verbal
learning AVL IR AVL DR Visual Learning Visual learning IR Visual Learning DR
Pre-op
Imm
Post
Op
3rd
month
post-
op
Pre-op
Imm
Post
Op
3rd
month
post-
op
Pre-op
Imm
Post
Op
3rd
month
post-
op
Pre-
op
Imm
Post
Op
3rd
month
post-
op
Pre-op
Imm
Post
Op
3rd
month
post-
op
Pre-op
Imm
Post
Op
3rd
month
post-
op
1 13 12 15 10 14 14 11 15 15 36 36 36 28 19 28 30 14 28
2 11 8 11 8 2 9 8 9 10 36 34 36 16.5 22 29 16.5 25 28
3 15 13 11 7 10 9 8 14 8 34 36 36 24 30 31 24 30 30
4 10 11 11 6 6 8 7 7 9 32 36 33 6 6 12 4 4 2
5 8 10 13 8 9 13 5 10 10 35 31 36 8 26 19.5 10 22 19.5
6 11 5 7 5 4 7 5 3 4 26.5 12 17 17 9 11.5 14 13 12
7 15 15 15 14 15 15 15 15 15 36 36 36 33 36 36 33 36 36
8 13 9 11 9 10 11 7 9 12 36 36 34 18 21 23 18 18.5 26
9 9 8 12 8 2 8 9 1 9 33 19 30 0 8 20 0 7 16
10 13 15 15 14 15 14 11 14 13 27 29 27.5 13 10 16 14.5 8 15.5
11 10 12 9 8 8 8 9 9 8 34 36 33 15 20.5 27 15 14 25
12 15 15 15 15 14 14 15 14 11 36 36 36 14 18.5 15.5 12.5 18.5 15
13 13 9 10 7 3 6 5 3 9 35 31 32 16 24 23 19 26 24
14 7 10 11 9 8 9 8 7 10 36 36 36 19 24 22 17 24 22
15 13 15 15 14 11 14 14 12 13 30 31 30 14 22 24 19 23 23
16 12 11 14 12 11 13 12 5 13 22 34 36 4.5 15.5 24 4.5 15 20
17 7 4 7 4 3 2 4 1 5 34 34 36 12.5 14.5 28 11 13.5 23
18 10 14 9 7 11 7 7 10 11 33 36 35 17 25 33 17 24 33
19 6 4 8 4 6 3 5 4 3 26 29 36 4 10 9 0 10 7
20 11 14 14 10 11 14 8 8 14 36 34 36 3 19 20 4 20 6.5
91
KEY TO MASTER CHART
Case No. – Case Number
IQ – Intelligence Quotient
Pre-op – Pre-operative score
Imm. Post-op – Immediate post-operative score
3rd
month post-op – 3rd
month post-operative score
AVL – Auditory & Verbal Learning
IR – Immediate Recall
DR – Delayed Recall
92
93
94
95
CONSENT FORM
I___________________________________________ aged _______,
son/daughter of ___________________________________
(Please tick boxes)
•Declare that I have read the above information provide to me regarding
the study: Cognitive effects of anterior temporal lobe resection
and have clarified any doubts that I had. [ ]
• I also understand that my participation in this study is entirely voluntary
and that I am free to withdraw permission to continue to participate at
any time without affecting my usual treatment or my legal rights [ ]
• I understand that my participation in the study will not influence the usual course of my
treatment in the hospital [ ]
• I understand that the study staff and institutional ethics committee
members will not need my permission to look at my health records even if I
withdraw from the trial. I agree to this access [ ]
• I understand that my identity will not be revealed in any information
released to third parties or published [ ]
• I voluntarily agree to take part in this study [ ]
• I received a copy of this signed consent form [ ]
Name: Signature:
Date:
Name of witness:
Relation to participant:
Date:
(Person Obtaining Consent) I attest that the requirements for informed consent for the medical
research project described in this form have been satisfied. I have discussed the research project
with the participant and explained to him or her in nontechnical terms all of the information
contained in this informed consent form, including any risks and adverse reactions that may
reasonably be expected to occur. I further certify that I encouraged the participant to ask
questions and that all questions asked were answered.
______________________________
Name and Signature of Person Obtaining Consent
96
97
CASE PROFORMA:
Proforma Serial No:
Diagnosis:
Date of Surgery:
Side of Surgery:
Neuropsychological
Test
Pre-
op
Imm
Post-
op
3rd
month
Post-
op
IQ
Pitch Recognition
Rhythm
Recognition
Timbre
Recognition
Loudness
Recognition
Facial Recognition
Facial Emotion
Recognition
Emotion Situation
Recognition
Auditory & Verbal
Learning (IR)
Auditory & Verbal
Learning (DR)
Visual Learning
(IR)
Visual Learning
(DR)