Surgery for Epilepsy

doi:10.1016/S0733-8619(18)31039-9

Neurologic Clinics

Volume 3, Issue 2, May 1985, Pages 313-330

https://doi.org/10.1016/S0733-8619(18)31039-9 Get rights and content

Surgical options for medically uncontrolled seizures include cortical resection corpus callosotomy, hemispherectomy, and stereotaxic lesions. Cortical resection, usually temporal lobectomy, is most widely used and most likely to effect cure in carefully selected patients. The selection criteria, methods of evaluation (including invasive recording techniques), indications, complications, and results of these various procedures are discussed.

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Cited by (78)

Current state of the art of traditional and minimal invasive epilepsy surgery approaches
2024, Brain and Spine
Open resective surgery remains the main treatment modality for refractory epilepsy, but is often considered a last resort option due to its invasiveness.
This manuscript aims to provide an overview on traditional as well as minimally invasive surgical approaches in modern state of the art epilepsy surgery.
This narrative review addresses both historical and contemporary as well as minimal invasive surgical approaches in epilepsy surgery. Peer-reviewed published articles were retrieved from PubMed and Scopus. Only articles written in English were considered for this work. A range of traditional and minimally invasive surgical approaches in epilepsy surgery were examined, and their respective advantages and disadvantages have been summarized.
The following approaches and techniques are discussed: minimally invasive diagnostics in epilepsy surgery, anterior temporal lobectomy, functional temporal lobectomy, selective amygdalohippocampectomy through a transsylvian, transcortical, or subtemporal approach, insulo-opercular corticectomies compared to laser interstitial thermal therapy, radiofrequency thermocoagulation, stereotactic radiosurgery, neuromodulation, high intensity focused ultrasound, and disconnection surgery including callosotomy, hemispherotomy, and subpial transections.
Understanding the benefits and disadvantages of different surgical approaches and strategies in traditional and minimal invasive epilepsy surgery might improve the surgical decision tree, as not all procedures are appropriate for all patients.
Minimally invasive keyhole temporal lobectomy approach for supramaximal glioma resection: A safety and feasibility study
2020, Journal of Clinical Neuroscience
Citation Excerpt :
Most importantly, care must be taken during the resection of the dominant temporal lobe, as these surgeries are almost always performed awake in order to adequately map the language center [17,18]. In addition, deep structures within the temporal stem such as the basal ganglia, as well as adjacent cranial nerve and vascular structures, must be avoided to prevent serious complications [19]. Thus visualization of these important anatomical regions is essential in performing a successful temporal lobectomy while minimizing the risk for collateral damage.
With a recent trend towards supra-maximal resection for gliomas and minimally invasive techniques, keyhole temporal lobectomies may serve an important role in neurosurgical oncology. Due to their location and proximity to eloquent brain, temporal lobe gliomas offer unique challenges that may limit the extent of resection. Here we describe a modified technique using mini-craniotomies through a keyhole approach for temporal lobectomies in glioma patients. We retrospectively reviewed data from consecutive patients who underwent temporal lobectomies for resection of gliomas from 2012 to 2018. Demographic data, extent of tumor resection, pre and post-op KPS, short term and long term complications, as well as other relevant data were collected. We identified 57 patients who underwent keyhole-mini craniotomy for temporal lobectomies for glioma. Surgical procedures were performed in 12 patients for low-grade glioma (LGG) and 45 patients for high-grade glioma (HGG). Awake craniotomies were performed in 15 of the cases, and 13 cases were for tumor recurrence. Supra-maximal resection (SMR) was achieved in 15 patients, while gross total resection (GTR) and near total resection (NTR) achieved in 32 patients and 10 patients, respectively. Average pre- and post-op KPS were equivalent, and post-operative complications requiring surgical intervention were experienced in 4 patients. Here we show that our modified keyhole craniotomy is both safe and effective in achieving SMR or GTR in glioma patients, with minimal morbidity. This minimally-invasive temporal lobectomy may be an instrumental tool for neurosurgical oncologists transitioning to less invasive techniques.
Knowledge of language function and underlying neural networks gained from focal seizures and epilepsy surgery
2019, Brain and Language
Citation Excerpt :
However, some language functions have rarely been studied, such as evaluating natural speech production/discourse and timing of verbal responses. We will start with the most common surgical syndrome of TLE, which likely represents 60–70% of all epilepsy surgical cases (Spencer & Spencer, 1985). As the temporal lobes contain structures and pathways that are clearly part of the classic language networks of Wernicke and Broca, and their interconnecting white matter fibers (e.g., arcuate fasciculus), the involvement of language functions in the symptomatology of this disorder is not surprising.
The effects of epilepsy and its treatments have contributed significantly to language models. The setting of epilepsy surgery, which allows for careful pre- and postsurgical evaluation of patients with cognitive testing and neuroimaging, has produced a wealth of language findings. Moreover, a new wave of surgical interventions, including stereotactic laser ablation and radio frequency ablation, have contributed new insights and corrections to language models as they can make extremely precise, focal lesions. This review covers the common language deficits observed in focal dyscognitive seizure syndromes. It also addresses the effects of surgical interventions on language, and highlights insights gained from unique epilepsy assessment methods (e.g., cortical stimulation mapping, Wada evaluation). Emergent findings are covered including a lack of involvement of the hippocampus in confrontation word retrieval, possible roles for key white matter tracts in language, and the often-overlooked basal temporal language area. The relationship between language and semantic memory networks is also explored, with brief consideration given to the prevailing models of semantic processing, including the amodal Hub and distributed, multi-modal processing models.
Intracranial electrodes monitoring improves seizure control and complication outcomes for patients with temporal lobe epilepsy - A retrospective cohort study
2018, International Journal of Surgery
Anterior temporal lobectomy (ATL) is the standard surgical treatment for temporal lobe epilepsy (TLE), but patients may suffer from recurrent seizures post-surgery. Invasive electrical monitoring plays a critical role in precisely identifying the epileptic foci. This study aimed to evaluate and compare the benefits of long-term invasive electroencephalography (EEG) monitoring and two-stage surgery with the classical approach to examine their effect on post-surgical brain function and complications.
Patients with TLE (N = 198) who underwent epilepsy surgery were retrospectively evaluated. Diagnosis of TLE was confirmed based on clinical grounds (semiology), EEG findings, and magnetic resonance imaging (MRI). Long-term invasive video EEG was performed; epileptiform discharges were recorded. Patients underwent either classical ATL or modified two-step surgery with electrodes implantation. Histopathological examination was performed. The patients were followed up at 1, 3, and 5 years after surgery.
Twenty-three and 175 patients underwent classical ATL and two-stage surgery, respectively. On histopathological examination, inflammation, hippocampal sclerosis, and cortical dysplasia were found to be the leading pathological causes of epileptic foci in both groups. MRI results were not consistent with the pathological findings. Grade II and III Engel scores were more frequent in the ATL group compared to two-stage surgery during follow-up. No postoperative complications were reported in two-stage surgery during follow-up, but one patient had mild hemiplegia in the ATL group.
Preoperative invasive monitoring with long-term EEG helps locate the epileptic foci precisely. Postsurgical complications are rare compared to classical ATL, with better prognosis and seizure freedom after surgery.
Seizure outcome following primary motor cortex-sparing resective surgery for perirolandic focal cortical dysplasia
2016, International Journal of Surgery
We present a case series of patients who underwent perirolandic resection for medically refractory focal epilepsy due to focal cortical dysplasia (FCD). Our aim was to specifically evaluate the outcome of a surgical strategy intended for seizure freedom while preserving primary motor cortex function.
Thirteen patients undergoing perirolandic resection for pharmacoresistant focal epilepsy between 2010 and 2015 who demonstrated histological evidence of FCD were selected from a prospectively maintained database. Presurgical evaluation included video EEG telemetry and 3T MRI brain for all patients. Eight patients underwent interictal FDG PET scan. Intracranial EEG monitoring was done for 8 patients – six by conventional subdural grid and depth electrodes and two by Stereo EEG. Additional techniques included extraoperative cortical stimulation mapping, intraoperative electrocorticography (ECoG), intraoperative motor cortex mapping and awake surgery in various combinations. In all cases (lesional and nonlesional), resection was intentionally limited for anatomic preservation of the primary motor cortex.
Amongst the thirteen patients with age ranging 14–44 years (mean 26.8 ± 9.2) 62% of them had daily seizures. MRI abnormalities were identified in 8 patients (62%), PET showed concordant findings in 7 patients (88%). When utilized, the mean duration of intracranial EEG recordings was 8.0 ± 7.2 days (range 2–23 days). All patients underwent a primary motor cortex-sparing resection of the suspected epileptogenic cortex. The mean postoperative follow up period was 23 months (range 7.5–62 months). Twelve out of 13 (92%) were seizure free (Engel 1) outcome at the last follow-up assessment; one patient had Engel 2a outcome at 28 months. Six patients (46%) had immediate new focal neurological deficits, however all six patients had recovered completely within three months.
The surgical strategy of a primary motor cortex-sparing resective surgery for perirolandic FCD is associated with an excellent early seizure-freedom rate and no permanent neurological deficits. Since the ultimate goal of resective epilepsy surgery is seizure freedom with simultaneous functional preservation, similar long term outcome studies should ultimately guide the resection strategy.
Minimally invasive surgical approaches for temporal lobe epilepsy
2015, Epilepsy and Behavior
Citation Excerpt :
It is first important to establish whether one is operating on the dominant or nondominant hemisphere, as this will impact how far posteriorly the resection can be made on the lateral cortical surface of the temporal lobe. The authors suggest that it is safe to resect 4–4.5 cm of temporal lobe on the dominant hemisphere to avoid injury to language areas and 5.5 cm on the nondominant side [5,25]. The vein of Labbé is another structure that can limit the extent of posterior resection and should also be visualized and protected throughout the procedure.
Surgery can be a highly effective treatment for medically refractory temporal lobe epilepsy (TLE). The emergence of minimally invasive resective and nonresective treatment options has led to interest in epilepsy surgery among patients and providers. Nevertheless, not all procedures are appropriate for all patients, and it is critical to consider seizure outcomes with each of these approaches, as seizure freedom is the greatest predictor of patient quality of life. Standard anterior temporal lobectomy (ATL) remains the gold standard in the treatment of TLE, with seizure freedom resulting in 60–80% of patients. It is currently the only resective epilepsy surgery supported by randomized controlled trials and offers the best protection against lateral temporal seizure onset. Selective amygdalohippocampectomy techniques preserve the lateral cortex and temporal stem to varying degrees and can result in favorable rates of seizure freedom but the risk of recurrent seizures appears slightly greater than with ATL, and it is not clear whether neuropsychological outcomes are improved with selective approaches. Stereotactic radiosurgery presents an opportunity to avoid surgery altogether, with seizure outcomes now under investigation. Stereotactic laser thermo-ablation allows destruction of the mesial temporal structures with low complication rates and minimal recovery time, and outcomes are also under study. Finally, while neuromodulatory devices such as responsive neurostimulation, vagus nerve stimulation, and deep brain stimulation have a role in the treatment of certain patients, these remain palliative procedures for those who are not candidates for resection or ablation, as complete seizure freedom rates are low. Further development and investigation of both established and novel strategies for the surgical treatment of TLE will be critical moving forward, given the significant burden of this disease.

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