Epilepsy & Behavior 24 (2012) 194198

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Review

Naming outcomes of anterior temporal lobectomy in epilepsy patients: A systematic

review of the literature
Victoria Lyn Ives-Deliperi a,, James Thomas Butler b, c
a
Department of Human Biology, University of Cape Town, South Africa
b
Department of Neurology, University of Stellenbosch, South Africa
c
Department of Neurology, University of Cape Town, South Africa

a r t i c l e i n f o a b s t r a c t

Article history: Anterior temporal lobectomy (ATL) is the standard surgical treatment for medically intractable temporal lobe
Received 19 March 2012 epilepsy (TLE). While seizure outcome is favorable, cognitive outcomes are a concern, particularly in respect of
Revised 2 April 2012 memory and naming. A systematic review of the literature on the naming outcomes of ATL is presented in this
Accepted 3 April 2012
article. Searches were conducted on PubMed and PsycInfo, yielding a total of 93 articles, 21 of which met in-
Available online 7 May 2012
clusion criteria. Declines in visual naming are common following ATL in the dominant hemisphere, and partic-
Keywords:
ularly, for naming living stimuli or famous faces. The Boston Naming Test (BNT) declines by a mean of 5.8
Naming points, exceeding the Reliable Change Index (RCI). There are no reports of decits in auditory naming follow-
Dysnomia ing ATL, despite the fact that auditory naming has shown to be a more sensitive measure of dysnomia than the
Epilepsy BNT in TLE patients. The absence of structural hippocampal pathology and late-onset epilepsy are the stron-
Surgery gest predictors of naming decline. Recommendations are made for further study.
ATL 2012 Elsevier Inc. All rights reserved.
Neuropsychology
Aphasia
Cognition
Anterior temporal lobe
Language

1. Introduction While seizure control is of primary interest in the surgical treat-

The surgical treatment of medically intractable temporal lobe epilep-
sy (TLE) is highly effective in controlling seizures [1,2]. Anterior tempo-
ral lobectomy (ATL) is the standard surgical procedure for TLE; while
seizure outcome has been shown to be favorable, post-operative de-
clines in cognitive performance are frequently reported. Verbal memory
and naming are the two cognitive modalities at the greatest risk of de-
cline following ATL performed in the language-dominant hemisphere
[3,4]. Post-operative naming declines are observed in between 25 and
60% of patients undergoing ATL [5]. There are no reports of naming de-
cline following non-dominant hemisphere resection. A recent systemat-
ic review calculating pooled estimates of neuropsychological outcomes
after temporal lobe resections reported a 44% risk of decline in verbal
memory and 34% risk of decline in naming after left-sided surgery [4].
No signicant declines in IQ were found following ATL in the dominant
hemisphere, and improvements in verbal uency and executive func-
tioning were reported. In addition, quality of life has been shown to sig-
nicantly improve in surgically-treated TLE patients compared to
medically-treated patients [2].
Corresponding author at: 209(b) Mediclinic Constantiaberg, Burnham Road,
Plumstead, 7800, South Africa. Fax: + 27 21 7979960.
E-mail address: vives@mweb.co.za (V.L. Ives-Deliperi).
ment of TLE, preserving or improving cognitive outcome is equally
important. For this reason, there has been a growing application of
more selective surgical procedures expected to reduce post-
operative cognitive impairment [6,3]. In the case of the standard
ATL, 36 cm of anterior temporal neocortex is resected along with
the amygdala and hippocampus, while in more selective procedures,
like the selective amygdalohippocampectomy (SAH), the amygdala,
hippocampus, and parahippocampal gyrus are resected and the neo-
cortex is spared as far as possible [7]. There is a lack of evidence to
show that more selective procedures produce favorable cognitive
outcomes, and further research in this area is required. In order to
support such research, it is important to review the neural substrates
of naming, elucidate the nature of naming decits following ATL, and
identify the assessments that are most sensitive and specic to such
declines.
Naming is the earliest milestone in linguistic development. Much
like the broader modality of language, naming relies on a number of
distinct but interacting cognitive processes and mental representa-
tions that are subserved by a distributed network of brain regions
[8,9]. Disruption to any of these regions can effect naming. In addition
to this, research has shown that specic categories of naming rely on
the functional integrity of discrete regions in the dominant hemi-
sphere. Distinctions have been made between regions supporting

1525-5050/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2012.04.115
 V.L. Ives-Deliperi, J.T. Butler / Epilepsy & Behavior 24 (2012) 194198 195

Table 1 2. Method
Inclusion and exclusion criteria for articles on naming outcomes following ATL.

Inclusion criteria
Original research article or literature review
Anterior temporal lobectomy
Adult temporal lobe epilepsy population
Pre- and post-surgical testing of naming
Exclusion criteria
Pediatric epilepsy population
living stimuli/ people and animals versus non-living stimuli/objects
[10,11], where the former rely on medial or posterior regions of dom-
inant temporal lobe and the latter on regions situated more anterior-
ly. Likewise, differential substrates are involved in visual versus
auditory naming tasks. As the label implies, visual naming, otherwise
referred to as confrontation naming, involves the presentation of
stimuli in the form of pictures or drawings; Auditory naming, also re-
ferred to as descriptive naming, involves generating the name from a
verbal description of a stimuli. Functional neuroimaging and electro-
cortical stimulation have shown visual naming to be subserved by
more posterior temporal lobe regions [12,13], and auditory naming
to rely on regions situated more anteriorly in the temporal lobe
[14,15]. To our knowledge, no research has been conducted on the
different regions involved in visual versus auditory category-specic
naming. The neural correlates of visual, auditory, and category-
specic naming are important considerations when investigating dys-
nomia as an outcome of different surgical resections.
The purpose of this review is to summarize what has been learned
about naming decits following ATL. This information is aimed to
guide further research on the differential outcomes of surgical inter-
ventions in the treatment of TLE.
A focused literature search was conducted using PubMed and
PsycInfo databases. Search terms included: epilepsy, surgery, naming,
dysnomia, and language. The initial search yielded 93 articles of
which 20 met inclusion criteria. Inclusion and exclusion criteria are
outlined in Table 1. Articles were retrieved and read in full, and refer-
ences were examined to identify additional studies. One additional
study was identied for inclusion through this process. Articles that
focused exclusively on pediatric populations were excluded, because
of potential confounding effects of language development on naming
outcome.
Particular attention was paid to the sample sizes in these studies,
the interval between surgery and post-operative testing, and the
instruments used to assess naming the type of naming assessed.
With these factors in mind, the primary interest was in the preva-
lence of reported post-operative dysnomia in patients undergoing
dominant-hemisphere resections. Secondary interests were in the
type of naming most vulnerable to decline following resection of
the anterior temporal lobe and factors predicting naming decline.
3. Results
Details of the 21 articles included in the review are presented in
Table 2. The sample sizes of the studies ranged from 17 to 217
(mean = 58). A 1-year interval between surgery and post-operative
cognitive testing is considered by some to be optimal [6], and four
of the studies reviewed relied on this interval or longer [1619],
while in 12, post-operative testing was conducted between 6 and
10 months following surgery [6,2030]. Post-operative testing was
conducted at two and three-week intervals in two studies [31,32]
and unspecied in the remaining three [3335].

Table 2
Details of the studies included in the review.

Date First Study type N Tasks Results Predictor

author

2010 Hamberger Prospective 45 (25 LH) ANT, VNT Signicant declines in VN following DH ATL, no declines in AN HS
2010 Kovac Retrospective 101 (50 LH) BNT Signicant declines in VN following DH ATL in patients with atypical Atypical dominance
language representation
2009 Schwarz Prospective 58 (24 LH) BNT Signicant decline in VN following DH ATL in patients with left TLE Impaired semantic
functions
2007 Hamberger Prospective 12 HS+ 12 HS ANT, VNT Signicant declines in VN following DH ATL only in patients without HS HS
2007 Yucus Retrospective 23 (LH) Custom CS Signicant declines in VN following DH ATL Age of seizure onset
2005 Davies Prospective 24 (LH) BNT Declines in VN greater than RCI in 54% of patients Age of seizure onset
2005 Liejten Retrospective 80 (LH) Custom VN No decline and some improvement in naming following tailored resection
2005 Schwarz Retrospective 45(LH) BNT Post-ATL decline equal to the RCI on BNT Seizure onset post
14 yrs
2003 Glosser Retrospective 63 + 10 BNT + custom CS Impaired naming of famous people in all groups, most signicant
controls in left ATL patients
2000 Bell Retrospective 48 (26 LH) BNT + custom CS 17 of 26 LH ATL patients demonstrated meaningful decline on BNT Age of word acquisition
2000 Strauss Prospective 79 (LH) BNT Signicant decline in naming following DH ATL, particularly for living things
1999 Hermann RCT 30 BNT + custom No signicant differences between the groups in naming
VN
1999 Hermann Retrospective 217 BNT Signicant declines in VN following DH ATL regardless of surgical Age of seizure onset
technique
1998 Davies Prospective 99 (LH) BNT + custom Signicant declines in VN following DH ATL. HS
VN Signicantly worse preop scores for HS +
1998 Seidenberg Prospective 88 (54 LH) VN-MAT Signicant declines in VN following DH ATL in non-MTLE group,
not in the MTLE group
1996 Langtt Retrospective 59 BNT Signicant decline in VN following DH ATL in 25% of patients
1996 Tippett Cross- 37 (17 LH) Custom VN Left ATL patients disproportionately impaired in naming non-living things
sectional
1995 Saykin Prospective 154 (85 LH) BNT Signicant declines in language overall after DH resection
1995 Davies Prospective 95 (53 LH) BNT No signicant declines in LHD ATL group
1994 Hermann Prospective 162 (85 LH) VN-MAT Mild decline in left group Age of seizure onset
1990 Stanaik Prospective 45 BNT Signicant decline in VN following ATL in 60% patients with no early risk

BNT, Boston Naming Test; ANT, Auditory Naming Test; VNT, Visual Naming Test; VN-MAT Visual Naming Test from the Multilingual Aphasia Test; HS, hippocampal sclerosis; LH, left
hemisphere.
196 V.L. Ives-Deliperi, J.T. Butler / Epilepsy & Behavior 24 (2012) 194198
The ndings of 14 of the 21 studies reviewed relied on results
from the Boston Naming Test (BNT) [6,16,1924,26,27,29,31,32,34],
two relied on results of the Visual Naming Test from the Multilingual
Aphasia Test battery [30,33], and the remaining two studies relied on
the results of customized visual naming tests [25,28], using line draw-
ing from Snodgrass and Vanderwart [36]. Two of the studies in the re-
view used both the Visual Naming Test (VNT) and Auditory Naming
Test (ANT) [17,18], and one used a single category-specic naming
assessment [35]. Of the 14 studies administering the BNT, one
added a category-specic naming task [31], and two ran additional
analyses to assess the differential effects of ATL on the naming of liv-
ing versus non-living items on the BNT (14 living:46 non-living)
[20,34].
Signicant declines in visual confrontation naming following
ATL were reported in all but two studies reviewed [16,23], and def-
icits in the naming of living versus non-living stimuli/famous faces
were reported in ve studies that measured category-specic nam-
ing [20,28,34,35,37]. No signicant changes in auditory naming
were reported.
Of the 14 studies in which results of the BNT were reported, signi-
cant declines on the measure post-ATL were noted in all but two [6,16].
In four of the 12 studies, reliable change indices (RCIs) were calculated
and naming declines exceeded the RCI in all cases [20,21,23,27]. Sig-
nicant declines following surgery were also reported in all of the
studies relying on customized visual naming assessments. Signicant
declines in visual naming were reported in both studies using the VNT
[17,18]. These results are depicted in Fig. 1.
Raw scores were used (where available) to calculate the aver-
age decline on the BNT in patients who underwent dominant-
hemisphere ATL across the studies reviewed, in the interest of asses-
sing whether overall change scores on the test exceeded the reported
RCI of 5 [38,39]. There was an average decline of 5.8 points on the
BNT for the pooled sample of patients (N = 495) across nine studies
that reported raw scores.
Of the 20 articles in this review reporting signicant declines in vi-
sual naming following ATL, 11 assessed predictors of post-operative
dysnomia. In six studies, late onset epilepsy was cited as a signicant
predictor of post-operative naming decline [20,21,27,29,30,35], and
three studies have shown the absence of hippocampal sclerosis to
be a signicant predictor of dysnomia [6,17,18,22]. Davies [22] and
Hermann [6] included both age of epilepsy onset and the absence of
hippocampal sclerosis in their analyses and found a stronger correla-
tion between naming declines and the absence of hippocampal
sclerosis.
Fig. 1. Naming outcomes of ATL with the number of studies that reported signicant post-operative declines in naming highlighted in red. BNT, Boston Naming Test; VNT, Visual
Naming Test; ANT, Auditory Naming Test; CS, category-specic naming tests.
4. Discussion
Dysnomia is frequently reported in patients with TLE, and naming
declines are observed in a high percentage of patients undergoing
ATL. In this review of the literature, signicant declines in naming fol-
lowing ATL in the dominant hemisphere were reported in 19 of the 21
articles reviewed. All of the reported declines were in visual confron-
tation naming. To date, there is no evidence of signicant post-
operative declines in auditory naming, even though auditory naming
has been shown to be auditory naming assessment has been shown in
TLE patients and is considered a closer analog to word-nding
difculties in daily life [23,40,41]. However, auditory naming was
only assessed in two of the 22 articles reviewed, and in one of these
studies, 24% of patients exhibited declines on the ANT [17]. In terms
of category-specic naming declines, there is evidence that the nam-
ing of living stimuli/famous faces is particularly vulnerable to decline
following ATL.
Paradoxically, ATL appears to carry a greater risk to visual naming
than to auditory naming, despite the evidence from cortical stimula-
tion and fMRI indicating that auditory naming systems are located in
the region resected, while visual naming systems are typically spared
[17]. Some authors have reasoned that improvements in executive
functioning following ATL, which are well described, may explain
the preservation of auditory naming, since this type of naming relies
more heavily on executive functioning [40]. Additionally, results of
cortical stimulation have shown that auditory naming sites are more
posteriorly distributed in patients with HS [17] and therefore spared
in ATL. Stratifying samples based on the presence or absence of HS
may therefore reveal signicant declines in auditory naming in sur-
gical patients without HS. Further research in this area is necessary.
Decits in the naming of living stimuli/famous faces appear to be
particularly vulnerable to anterior temporal lobe resection, as re-
ported in several studies reviewed [20,28,34,37]. These ndings are
consistent with what has been learned about the neural substrates
of category-specic naming: The functional integrity of the posterior
region of the dominant TL has been shown to be associated with the
naming of objects or non-living stimuli, and integrity of the anterior
region has been shown to be associated with the naming of living ob-
jects/famous faces [42,43]. Dysnomia, in the category of living stimuli,
has been reported in ATL patients in a recent study that did not meet
the inclusion criteria of this review, because a pre- and post-surgical
design was not employed, but nevertheless demonstrated signicant
decits in naming famous faces and animals in patients with dominant
anterior temporal lobe seizure onset/resection [44]. The authors note
 V.L. Ives-Deliperi, J.T. Butler / Epilepsy & Behavior 24 (2012) 194198
that naming and recognition decits were infrequently detected by
the BNT, which samples only a limited range of stimuli, and suggest
that category-specic naming decits may therefore have been unde-
tected. Decits in naming famous faces following resection of the an-
terior temporal lobe are consistent with the growing body of
literature on proper name anomia, which is described as a selective
anomia for famous people and places and is associated with anterior
temporal lobe pathology [11,44,45,46].
Several studies have assessed predictors of naming decline in TLE
patients undergoing ATL. The most commonly cited predictors are
late onset of epilepsy and the absence of structural hippocampal pa-
thology. These predictors are probably related to interhemispheric
and intrahemispheric reorganization of language and the role of the
hippocampus in higher-order visual processing [22,39,47]. The corre-
lation between late onset of seizures and the risk of post-operative
dysnomia is a robust nding [6,20,27,29,30,32,35]. Although earlier
onset of epilepsy is associated with an increased proportion of anterior
naming sites [48], presumably increasing the risk of dysnomia follow-
ing ATL, it has been suggested that these patients undergo reorganiza-
tion of the language-semantic-based knowledge system, rendering
some of the anterior temporal lobe nominal language sites redundant
in nominal speech [6]. More recent ndings have shown that early
onset of epilepsy and the associated functional disturbances interrupt
normal development and result in more diffuse language organization
[27]. Bell and colleagues [20] have added to this literature, dem-
onstrating that when naming declines following ATL, it is later-
acquired words that are most vulnerable to loss, presumably due to
the temporal gradient of encoded memories. Age of acquisition of
words has also been shown to predict the nature of naming decline
in aphasic patients and patients with semantic dementia [49].
The hippocampus in the dominant hemisphere is considered to play
a signicant role in the neural network involved in visual confrontation
naming [17,39,47,50]. The presence of hippocampal sclerosis in patients
with TLE appears to offer some protection against post-operative dys-
nomia, due to the potential redistribution of visual naming sites in re-
sponse to early hippocampal and associated pathology.
It is important to consider cognitive gains and losses that follow
ATL against those that may have occurred as a natural course of TLE.
Progressive cognitive decline in patients with TLE has been reported
previously, most notably for memory impairment [5154]. Seizure
frequency and left hippocampal atrophy have been associated with
such declines. One study reported a correlation between cognitive de-
cline and duration of epilepsy (duration ranging from 9 to 56 years),
with each year of epilepsy related to an increase in the impairment
index of 0.5% [54]. While these studies have been informative, many
rely on small samples and cross-sectional designs. Those patients
with the longest duration of epilepsy are likely to have the most se-
vere forms of temporal lobe epilepsy, and therefore, the most severe
hippocampal atrophy and the most severely impaired cognitive
performance. Hence, cross-sectional studies that nd an association
between age and cognitive performance, suggesting progressive cog-
nitive decline, may be confounded by the severity of the condition.
Not all authors have found worsening of cognitive performance
over time. In one study, cognitive decits associated with MTLE in
childhood remained stable across the adult lifespan, at least until
60 years of age, despite the intractable nature of the seizures [55].
Although none of these studies measured progressive declines in
naming per se, it may be reasonable to assume, should naming pro-
gressively decline at all over time, that such a decline would be pro-
tracted, as is the case with IQ and memory decline, and thus would
not confound the results of surgical outcomes.
Based on the summary of the literature on naming outcomes fol-
lowing ATL presented in this review, visual confrontation naming is
highly vulnerable to decline after ATL. The BNT has been the most
frequently used formal assessment of visual naming and, perhaps
because of this, the test that has reliably detected post-operative
197
dysnomia. Since ATL has been shown to carry a risk to the naming
of living versus non-living stimuli, and particularly the naming of
famous faces, including category-specic assessments may provide a
more sensitive measure of interval change than the BNT. This may
enhance current understanding of the systems involved in the com-
ponents of naming.
Further research is also recommended to determine the effects of
anterior temporal lobe resection on auditory naming, particularly in
patients without HS. Previous research has found non-signicant de-
clines in auditory naming following ATL. This may relate to the obser-
vation that auditory naming sites, in patients with HS, are more
posteriorly distributed and that HS is common in patients with TLE.
The confounding role of executive performance in auditory naming
and the differential neural substrates of visual versus auditory
category-specic naming of particular interest. In recent years, it
has also been shown that more selective surgical procedures and tai-
lored surgeries may present modestly less risk to naming [6,56]. This
needs to be conrmed in more robust studies applying randomized-
controlled designs, and taking into account what has been learned
from the literature on the nature of dysnomia following ATL.
Ethical publication
We conrm that we have read the Journal's position on issues in-
volved in ethical publication and afrm that this report is consistent
with those guidelines.
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