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Surgical treatment for epilepsy is arguably the most underutilized of all accepted therapeutic interventions in the entire field of medicine. There are many types of surgery performed for epileptic seizures due to conditions other than temporal lobe epilepsy (TLE). Early surgical intervention is particularly important when progressive features of an epileptic condition are present. The chapter summarizes...
Electroencephalography (EEG) with scalp electrodes can provide unique evidence of epileptogenicity and, as such, it has a pivotal role in the evaluation of patients with medically intractable epilepsy for epilepsy surgery. The putative epileptogenic zone is identified by evaluation of the interictal and ictal scalp EEG in concert with a variety of other structural and functional diagnostic modalities...
Epilepsy surgery is a neurosurgical procedure in which a cerebral area identified as being epileptogenic is removed or disconnected. In recent years, the quality of MRIs has increased along with its success in detecting the so‐called “epileptogenic lesion”. The location of the lesion and its nature once identified as possibly being epileptogenic, provide decisive information concerning the risk and...
The individual determination of interictal and ictal epileptic brain regions in relation to the functional cortex is a main task during presurgical evaluation of pharmacoresistent epilepsies. In addition to ictal semiology information about anatomy and morphology of lesions (MRI) EEG, SPECT, PET are used for detecting functional changes. MEG as a contactless, non‐invasive method with high temporal...
A presurgical evaluation starts with a complete seizure history, physical and neurological examination, routine scalp electroencephalography (EEG) and high‐resolution magnetic resonance imaging (MRI) of the brain to assess structural abnormalities. These investigations are complemented by video‐EEG monitoring, which allows evaluation of the clinical features of seizures, interictal and ictal EEG,...
A presurgical evaluation starts with a complete seizure history, physical and neurological examination, routine scalp electroencephalography (EEG) and high‐resolution magnetic resonance imaging (MRI) of the brain to assess structural abnormalities. These investigations are complemented by video‐EEG monitoring, which allows evaluation of the clinical features of seizures, interictal and ictal EEG,...
This chapter outlines the principles and clinical applications of neurophysiological techniques based on computational analysis of electroencephalogram (EEG) or magnetoen‐cephalography (MEG) activity. These techniques aim at localizing the sources of interictal and ictal paroxysmal signals in epilepsy or at assessing changes in functional connectivity inside the epileptic neuronal networks. The chapter...
Neuropsychological expertise depends on the use of sensitive tests and a solid database about those tests, and fortunately this is an area of growth. Overall, the field is maturing well and there are many instruments in current use for presurgical evaluation. This chapter provides a brief overview of some of these, organized primarily by brain region and beginning with the temporal lobes, as this...
Epilepsy surgery has revolutionized the management of patients with treatment‐resistant focal epilepsy. This chapter aims to make the case for a pre‐surgical psychiatric evaluation (PPE) in every surgical candidate. It tries to identify the obstacles precluding the performance of such evaluation. The chapter provides clinicians with practical and user‐friendly protocols that can even be performed...
Temporal lobe and other lobar surgeries for epilepsy have a long history, are well established and have shown better seizure outcome and decreased complication rates over time and with more experience in epilepsy centres. This chapter discusses the work‐up, efficacy and potential complications of temporal and other lobar resections for the control of epileptic seizures. Epilepsy surgery outcomes vary...
Primary brain tumours are important aetiological factors in patients with partial focal or localization‐related epilepsy. A chronic seizure disorder, often medically refractory, may be the only symptom of a brain neoplasm. The localization of the abnormal tissue lesion, that is the lesional zone, may indicate the site of seizure onset in the individual with symptomatic partial focal epilepsy. Surgical...
Vascular and infective lesions of the brain have a high propensity to induce seizures, and epilepsy is often the main or only symptom. This chapter tabulates the classification of vascular and infective lesions associated with intractable epilepsy. Increasingly sophisticated neuroimaging has improved detection rates of intracranial abnormalities in patients with epilepsy. In particular, MRI is sensitive...
Malformations of cortical development (MCDs) consist of a group of brain developmental anomalies. These disorders were originally named according to their gross anatomical appearances: polymicrogyria (PMG), schizencephaly, lissencephaly (LIS), hemimegalencephaly, grey matter heterotopia and focal cortical dysplasia (FCD). This chapter considers surgical treatment of refractory epilepsy due to various...
Hemispherotomy (HE) is a very effective surgical procedure, with a high rate of seizure control but with an irreversible contralateral motor and visual field deficit when unilateral hemispheric refractory epilepsy has been well documented. Once the hemispheric resection or disconnection is supposed to be complete, a failure to control seizures is most probably due to epileptogenic tissue within the...
Commissurotomy may successfully reduce seizure frequency and severity for certain patients who have failed medical management, who are not eligible for resective seizure surgery and who have either preferred not to undergo vagal nerve stimulation or failed to respond to that procedure. Atonic seizures and secondarily generalized major motor seizures are most likely to be improved, but other seizure...
This chapter reviews the clinical features, diagnosis and management of intrahypothalamic or sessile hypothalamic hamartomas (HH). Even within the intrahypothalamic subtype, variability in severity and evolution of the neurological symptoms exists. The tremendous clinical diversity of HH patients requires awareness by those providing care to this population. The chapter explains a list of treatment...
Multiple subpial transection (MST) is a palliative surgical disconnection procedure, which can be effective in the treatment of medically intractable epilepsy in select patient populations. It works by disrupting neuronal synchrony of epileptic activity in a critical circuit of neurons to stop the progression and expression of eileptiform activity and seizures. MST breaks up the epileptic neuronal...
This chapter examines the advances in functional brain imaging, neuroanaesthesia and neurosurgical technique that have contributed to the utility and efficacy of awake surgery for medically refractory temporal lobe epilepsy. Awake surgery with intraoperative functional stimulation mapping is surprisingly well tolerated by most patients. During the early years, all patients were operated awake; however,...
Children with therapy‐resistant epilepsy are at particular risk for developmental delay, cognitive regression and higher mortality rates. This chapter reviews the concepts of paediatric epilepsy surgery, with an emphasis on literature published in the last 10 years. It assists the paediatrician and neurologist in understanding the rationale behind early diagnosis of therapy resistance and, when appropriate,...
The complications of epilepsy surgery must include the complications from invasive procedures used in presurgical assessment as well as those arising in relation to therapeutic interventions. Intracranial electrodes have a complication rate that increases with the invasiveness and complexity of the procedure. Therapeutic procedures are divided into resective and functional operations. In resective...
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