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Current management and surgical outcomes of medically intractable epilepsy.
Clin Neurol Neurosurg 2013; 115(12):2411-8CN

Abstract

Epilepsy is one of the most common neurologic disorders in the world. While anti-epileptic drugs (AEDs) are the mainstay of treatment in most cases, as many as one-third of patients will have a refractory form of disease indicating the need for a neurosurgical evaluation. Ever since the first half of the twentieth century, surgery has been a major treatment option for epilepsy, but the last 10-15 years in particular has seen several major advances. As shown in relatively recent studies, resection is more effective for medically intractable epilepsy (MIE) than AED treatment alone, which is why most clinicians now endorse a neurosurgical consultation after approximately two failed regimens of AEDs, ultimately leading to decreased healthcare costs and increased quality of life. Temporal lobe epilepsy (TLE) is the most common form of MIE and comprises about 80% of epilepsy surgeries with the majority of patients gaining complete seizure-freedom. As the number of procedures and different approaches continues to grow, temporal lobectomy remains consistently focused on resection of mesial structures such as the amygdala, hippocampus, and parahippocampal gyrus while preserving as much of the neocortex as possible resulting in optimum seizure control with minimal neurological deficits. MIE originating outside the temporal lobe is also effectively treated with resection. Though not as successful as TLE surgery because of their frequent proximity to eloquent brain structures and more diffuse pathology, epileptogenic foci located extratemporally also benefit from resection. Favorable seizure outcome in each of these procedures has heavily relied on pre-operative imaging, especially since the massive surge in MRI technology just over 20 years ago. However, in the absence of visible lesions on MRI, recent improvements in secondary imaging modalities such as fluorodeoxyglucose positron emission computed tomography (FDG-PET) and single-photon emission computed tomography (SPECT) have lead to progressively better long-term seizure outcomes by increasing the neurosurgeon's visualization of supposed non-lesional foci. Additionally, being historically viewed as a drastic surgical intervention for MIE, hemispherectomy has been extensively used quite successfully for diffuse epilepsies often found in pediatric patients. Although total anatomic hemispherectomy is not utilized as commonly today, it has given rise to current disconnective techniques such as hemispherotomy. Therefore, severe forms of hemispheric developmental epilepsy can now be surgically treated while substantially decreasing the amount of potential long-term complications resulting from cavitation of the brain following anatomical hemispherectomy. Despite the rapid pace at which we are gaining further knowledge about epilepsy and its surgical treatment, there remains a sizeable underutilization of such procedures. By reviewing the recent literature on resective treatment of MIE, we provide a recent up-date on epilepsy surgery while focusing on historical perspectives, techniques, prognostic indicators, outcomes, and complications associated with several different types of procedures.

Authors+Show Affiliations

School of Medicine, Creighton University, Omaha, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

24169149

Citation

Ramey, Wyatt L., et al. "Current Management and Surgical Outcomes of Medically Intractable Epilepsy." Clinical Neurology and Neurosurgery, vol. 115, no. 12, 2013, pp. 2411-8.
Ramey WL, Martirosyan NL, Lieu CM, et al. Current management and surgical outcomes of medically intractable epilepsy. Clin Neurol Neurosurg. 2013;115(12):2411-8.
Ramey, W. L., Martirosyan, N. L., Lieu, C. M., Hasham, H. A., Lemole, G. M., & Weinand, M. E. (2013). Current management and surgical outcomes of medically intractable epilepsy. Clinical Neurology and Neurosurgery, 115(12), pp. 2411-8. doi:10.1016/j.clineuro.2013.09.035.
Ramey WL, et al. Current Management and Surgical Outcomes of Medically Intractable Epilepsy. Clin Neurol Neurosurg. 2013;115(12):2411-8. PubMed PMID: 24169149.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Current management and surgical outcomes of medically intractable epilepsy. AU - Ramey,Wyatt L, AU - Martirosyan,Nikolay L, AU - Lieu,Corinne M, AU - Hasham,Hasnain A, AU - Lemole,G Michael,Jr AU - Weinand,Martin E, Y1 - 2013/10/11/ PY - 2013/04/15/received PY - 2013/06/19/revised PY - 2013/09/29/accepted PY - 2013/10/31/entrez PY - 2013/10/31/pubmed PY - 2014/7/30/medline KW - AED KW - ATL KW - EEG KW - ETLE KW - Epilepsy KW - FDG-PET KW - HME KW - HS KW - Hemispherectomy KW - MIE KW - Outcome KW - RE KW - Rasmussen's encephalitis KW - SAH KW - Surgery KW - Temporal lobe epilepsy KW - anterior temporal lobectomy KW - anti-epileptic drug KW - electroencephalography KW - extratemporal lobe epilepsy KW - fluorodeoxyglucose positron emission computed tomography KW - hemimegalencephaly KW - hippocampal sclerosis KW - medically intractable epilepsy KW - selective amygdalohippocampectomy SP - 2411 EP - 8 JF - Clinical neurology and neurosurgery JO - Clin Neurol Neurosurg VL - 115 IS - 12 N2 - Epilepsy is one of the most common neurologic disorders in the world. While anti-epileptic drugs (AEDs) are the mainstay of treatment in most cases, as many as one-third of patients will have a refractory form of disease indicating the need for a neurosurgical evaluation. Ever since the first half of the twentieth century, surgery has been a major treatment option for epilepsy, but the last 10-15 years in particular has seen several major advances. As shown in relatively recent studies, resection is more effective for medically intractable epilepsy (MIE) than AED treatment alone, which is why most clinicians now endorse a neurosurgical consultation after approximately two failed regimens of AEDs, ultimately leading to decreased healthcare costs and increased quality of life. Temporal lobe epilepsy (TLE) is the most common form of MIE and comprises about 80% of epilepsy surgeries with the majority of patients gaining complete seizure-freedom. As the number of procedures and different approaches continues to grow, temporal lobectomy remains consistently focused on resection of mesial structures such as the amygdala, hippocampus, and parahippocampal gyrus while preserving as much of the neocortex as possible resulting in optimum seizure control with minimal neurological deficits. MIE originating outside the temporal lobe is also effectively treated with resection. Though not as successful as TLE surgery because of their frequent proximity to eloquent brain structures and more diffuse pathology, epileptogenic foci located extratemporally also benefit from resection. Favorable seizure outcome in each of these procedures has heavily relied on pre-operative imaging, especially since the massive surge in MRI technology just over 20 years ago. However, in the absence of visible lesions on MRI, recent improvements in secondary imaging modalities such as fluorodeoxyglucose positron emission computed tomography (FDG-PET) and single-photon emission computed tomography (SPECT) have lead to progressively better long-term seizure outcomes by increasing the neurosurgeon's visualization of supposed non-lesional foci. Additionally, being historically viewed as a drastic surgical intervention for MIE, hemispherectomy has been extensively used quite successfully for diffuse epilepsies often found in pediatric patients. Although total anatomic hemispherectomy is not utilized as commonly today, it has given rise to current disconnective techniques such as hemispherotomy. Therefore, severe forms of hemispheric developmental epilepsy can now be surgically treated while substantially decreasing the amount of potential long-term complications resulting from cavitation of the brain following anatomical hemispherectomy. Despite the rapid pace at which we are gaining further knowledge about epilepsy and its surgical treatment, there remains a sizeable underutilization of such procedures. By reviewing the recent literature on resective treatment of MIE, we provide a recent up-date on epilepsy surgery while focusing on historical perspectives, techniques, prognostic indicators, outcomes, and complications associated with several different types of procedures. SN - 1872-6968 UR - https://www.unboundmedicine.com/medline/citation/24169149/Current_management_and_surgical_outcomes_of_medically_intractable_epilepsy_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0303-8467(13)00389-2 DB - PRIME DP - Unbound Medicine ER -