No link between piriform cortex subregion resection and seizure freedom in two cohorts with temporal lobe epilepsy.

Overview

1. School of Medicine, Department for Neurology, Philipps-Universität Marburg, Baldingerstr, 35043 Marburg, Germany
2. Center for Mind, Brain and Behavior (CMBB), Philipps-Universität Marburg, Marburg, Germany
3. Institute of Medical Physics and Radiation Protection, Technische Hochschule Mittelhessen, Giessen, Germany
4. School of Medicine, Department for Neuroradiology, Philipps-Universität Marburg, Marburg, Germany
5. School of Medicine, Department for Neurosurgery, Philipps-Universität Marburg, Marburg, Germany
6. Goethe-University Frankfurt, LOEWE Center for Personalized Translational Epilepsy Research (Cepter), Frankfurt Am Main, Germany

Abstract

Background: Postoperative seizure freedom in temporal lobe epilepsy (TLE) has been linked to the extent of piriform cortex resection. Earlier work used manual piriform cortex segmentations truncated at the limen insulae and overlapping the amygdala. We re-evaluated this association using an investigator-independent, connectivity-based segmentation.

Methods: Patients with TLE who underwent mesiotemporal epilepsy surgery at a single center with > 1-year postoperative follow-up were included retrospectively (discovery cohort). Postoperative images and connectivity-defined piriform cortex subregions were registered to preoperative T1-weighted scans. Additional manual piriform cortex segmentation was performed for comparison. The extent of resection within temporal lobe subregions was compared between seizure-free (ILAE I) and non-seizure-free patients. Results were validated using a large independent cohort. For additional validation, voxel-based lesion-outcome mapping was performed using logistic regression.

Results: Twenty-eight patients (15 female) with TLE of heterogeneous etiologies were included in the discovery cohort. No significant association between ILAE outcome and the extent of resection within manually or automatically defined piriform cortex was observed. Extensive analyses in the validation cohort (n = 305, 205 with hippocampal sclerosis) confirmed this result. Additional voxel-based lesion-outcome mapping (n = 305) showed no significant associations with ILAE I outcome. Resected proportions within other mesiotemporal regions were not associated with ILAE I outcome.

Conclusion: No association between ILAE outcome and the resected proportion of specific mesiotemporal structures was detected. This result was robust across cohorts, piriform cortex definitions and analytical approaches. These results differ from previous reports and suggest that piriform cortex resection should be considered on an individualized basis rather than routinely incorporated into temporal lobe resections.

Supplementary Information: The online version contains supplementary material available at 10.1007/s00415-026-13850-w.

Reproduced under the paper's license (CC BY), from the paper cited above.

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Data

Datasets cited

• doi:10.18112/openneuro.ds005602.v1.0.0, at OpenNeuro; found in the references
• openneuro:ds005602, at OpenNeuro; found in “Data availability”

Data availability

Data from the discovery cohort is not available for reasons of data protection. The validation cohort is freely available under https://openneuro.org/datasets/ds005602/versions/1.0.0. Code for data analyses is available on request.

Reproduced under the paper's license (CC BY), from the paper cited above.

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Version 2, 28 September 2026

• Publisher: n/a → Springer Science+Business Media

Version 1, 28 September 2026: the first record

Recorded: type, language, journal, volume, issue, pages, dates, 11 authors, 6 keywords, 15 MeSH terms, 2 funders, 52 references.

Cite

This paper

Zahnert, F., Pfanzelt, F., Menzler, K., Habermehl, L., Keil, B., Timmermann, L., Kemmling, A., Grote, A., Nimsky, C., Knake, S., & Belke, M. (2026). No link between piriform cortex subregion resection and seizure freedom in two cohorts with temporal lobe epilepsy. Journal of neurology, 273(6), 335. https://doi.org/10.1007/s00415-026-13850-w

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