Why is There Still Doubt to Cut it Out?

Abstract

The modern era of surgical treatment for epilepsy began in the late nineteenth century. The epileptogenic region was originally localized on the basis of seizure semiology and identification of a structural lesion, which was then superseded by the advent of EEG in the mid-twentieth century (1). Introduction of advanced neuroimaging by the end of the twentieth century-first PET and then MRI-returned presurgical evaluation to a more lesion-directed approach, with EEG often playing a confirmatory role. SPECT, MEG, and fMRI also contribute to the identification of previously invisible lesions, such as hippocampal sclerosis in patients with mesial temporal lobe epilepsy (MTLE), as well as malformations of cortical development (MCD), particularly in infants and young children. Advances in operative techniques have greatly improved the safety, as well as the efficacy, of epilepsy surgery. As a result, not only are we achieving better outcomes today, but many patients are receiving surgery who would not have been considered surgical candidates a decade ago. Furthermore, procedures are now sufficiently cost-effective to permit establishment of epilepsy surgery programs in countries with limited resources (2). A major remaining challenge is establishment of biomarkers that reliably localize and determine the extent of the epileptogenic region, particularly in patients without obvious structural lesions (3). Surgical ApproachesVarious therapeutic surgical procedures are performed for intractable epilepsy today (Table 1), depending upon the type of epilepsy and the location of the epileptogenic region. Approaches to presurgical evaluation vary according to the type of surgical procedure to be performed. These procedures can be categorized into standardized resections, tailored resections, disconnections, and stereotactic ablations. Deep-brain stimulation (4) and responsive cortical stimulation (5) are beyond the scope of this discussion.The most common standardized surgical resection and, indeed, the most common type of surgery performed for Surgical treatment for epilepsy has made tremendous strides in the past few decades as a result of advances in neurodiagnostics-particularly structural and functional neuroimaging-and improved surgical techniques. This has not only resulted in better outcomes with respect to epileptic seizures and quality of life, and reduced surgical morbidity and mortality, but it has also increased the population of patients now considered as surgical candidates, particularly in the pediatric age range, and enhanced cost-effectiveness sufficient to make surgical treatment available to countries with limited resources. Yet surgical treatment for epilepsy remains arguably the most underutilized of all accepted medical interventions. In the United States, less than 1% of patients with pharmacoresistant epilepsy are referred to epilepsy centers.Although the number of epilepsy surgery centers has increased appreciably over the past two decades, the number of therapeutic surgical procedures performed for e...

Emerging surgical therapies in the treatment of pediatric epilepsy

“…The reluctance to refer patients for evaluation at an epilepsy center is multifactorial, with reasons for delay including fear of surgical comorbidity, expense, and limited experience with modern, multidisciplinary treatment options (6). The recent emergence of novel surgical diagnostic and therapeutic strategies has the potential to increase the number of children who can benefit from surgical therapy, improve its efficacy, and decrease morbidity.…”

“…Although it was initially perceived as a therapeutic option only after all other options were exhausted, surgical treatment of properly selected patients can provide long-term seizure control rates of 50-70% (5). In fact, surgical intervention remains grossly underutilized, with approximately 100,000-500,000 surgical candidates in the U.S. but less than one percent of eligible patients undergoing epilepsy surgery each year (6). In light of improved seizure-control rates and reduced morbidity of modern epilepsy treatments, the American Academy of Neurology published a practice parameter recommending surgery as a treatment of choice for certain patients with DRE, as earlier referral can help avoid the adverse developmental and social effects of uncontrolled seizures (7).…”

Deep Brain Stimulation for the Treatment of Epilepsy: Circuits, Targets, and Trials

“…Mesial temporal lobe epilepsy (MTLE) is the most common form of medically refractory epilepsy and enjoys a high rate of seizure freedom following amygdalohippocampal resection [3,5,8,57]. However, hippocampal resection or ablation may be contraindicated in cases of dominant-onset MTLE with preserved verbal memory, cases with bilateral mesial temporal onsets, or recurrent MTLE contralateral to a prior resection.…”

Surgical advancements in pediatric epilepsy surgery: from the mysterious to the minimally invasive

“…Further, early age of seizure onset and pharmacoresistance are risk factors for poor cognitive development (4), and seizure freedom after surgery is likely to rescue that downward trajectory. Unfortunately, at this time, most children with DRE still endure years of seizures before surgical evaluation, and epilepsy surgery remains among the most under-utilized therapies in modern medicine (5).…”