Clinics in Neurology ISSN: 2692-7934 Review Article Epilepsy Surgery - A Short Update Ganapathy S* and Nair R Department of Neurosurgeon & Spine Surgeon, Manipal Institute of Neurological Disorders (MIND), India Abstract Epilepsy surgery has been rapidly progressing over the last decade or so, with many previously untreatable conditions now satisfactorily managed to allow improved quality of life and seizure control without excessive medication and debilitating neurological deficits. We present a brief recap on accepted axioms of epilepsy surgery with a look at the future with a short summary of seizure disorder itself and the various management options. Keywords: Drug recalcitrant epilepsy; Intractable epilepsy; Epilepsy surgery; Temporal love epilepsy Introduction 2. The occurrence of an average of one seizure per month for at least 18 months, and Epilepsy surgery has been the ugly sister of neurosurgery’s charmed souls vascular and skull base surgery. But in the last decade 3. No more than 3 months of seizure-free hiatus during those or so, it has occupied an enviable niche for drug recalcitrant epilepsy 18 months. especially in children. We explain the basic concepts of Epilepsy Surgically remediable conditions surgery along with suitable examples below. Surgery has traditionally been recommended for tumors Indications precipitating epilepsy. The definition has been expanded to include, Patients with refractory epilepsy are generally suitable for one or vascular lesions such as cavernomas, Arteriovenous malformations, more procedure. The aim is to either enable seizure free survival or aneurysms and hemangioblastomas, developmental malformations marked decrease in seizure frequency and intensity enabling better such as hemimegaloencephaly, cortical dysplasia’s, porencephaly, quality of life. Epilepsy which is disabling in any way is a candidate for lissencephaly and others, scar epilepsy, infectious lesions such as invasive investigations and eventual surgery. All that is expected is an abscesses, empyema and encephalitis, strokes and other ischemic acceptable risk to benefit ratio. insults, and finally traumatic injuries. The lesions are summarized Contraindications in Diagram 1, where epilepsy has been divided into Temporal, Extra temporal, and generalized epilepsy (also called catastrophic epilepsy). There are a few diseases that are not suitable for surgery. These include disorders such as Idiopathic age-related epilepsies, Progressive Surgical options underlying neurological diseases, infectious causes, severe mental Surgery can be classified as listed in Diagram 2. There can be retardation, and psychopathology. An incapability to comprehend resective options such as topectomies, lesionectomies and lobectomies, and cooperate with the procedure can also be problematic as some disconnections such as callosotomies, hemispherotomies, procedures require the patient to stay away during surgery and Neuroaugmentative surgery such as anterior thalamic nucleus DBS cooperate in an intimate manner. Bilateral, independent inter ictal and/ and vagal stimulation and finally radio surgery. or ictal EEG involvement also makes surgery difficult. Involvement of Patient evaluation eloquent cortex by even benign lesions makes surgery difficult as post op deficits become unavoidable. Unrealistic expectations at the end of All patient evaluation must be done holistically as a the day are the most difficult and painful obstacle to surmount in the multidisciplinary team approach. Diligent an intensive evaluation is charge to improve quality of life. essential to ensure good outcomes and prevent unnecessary surgery. Investigation is divided into 2 phases: I and II as shown in Diagram 3. Intractability Phase I Stringent criteria for medical intractability as defined are: This phase includes non-invasive investigations to attempt 1. Failure of two appropriate anticonvulsants, localization of the epileptic focus over the surface of the brain before Citation: Ganapathy S, Nair R. Epilepsy Surgery - A Short Update. deciding upon surgery and approach. The phase consists of: Clin Neurol. 2020;1(2):1008. History & examination: An accurate history and examination Copyright: © 2020 Ganapathy S provide a window into the semiology of the disease. Important Publisher Name: Medtext Publications LLC points to ask and investigate include Auras, Seizure onset, progression, completion, Aphasias, manual automatisms, any and th Manuscript compiled: June 05 , 2020 all neurological deficits and lastly neurocutaneous syndromes. 2 or *Corresponding author: Ganapathy S, Department of Neurosurgeon more semiologies would be possible if multifocal epilepsy is present & Spine Surgeon, Manipal Institute of Neurological Disorders (MIND), (Table 1). Localization of the seizure focus based on Language (Table Manipal Hospital Bangalore, 13 Waterwoods, Varthur road, Rama- 2), Autonomic phenomena (Table 3), Motor symptoms (Table 4) and gondanahalli, Bangalore 560066, India, Tel: +0-9686617831; E-mail: examination findings (Table 5) are summarized as stated. [email protected] © 2020 - Medtext Publications. All Rights Reserved. 016 2020 | Volume 1 | Article 1008 Clinics in Neurology Temporal Lobe seizures can be separated into 1. Limbic seizures arising from the amygdala (80%). 2. Antero infero-mesial seizures arising from the entorhinal cortex & hippocampus area. 3. Neocortical seizures arising from the neocortex. The auditory illusory auras may originate from either side of temporal neocortex. Frontal lobe seizures: These are much briefer than their temporal lobe counterparts and are associated with less post-ictal confusion but are more motor in their characteristics. They are more likely to be involved with secondary generalization but are less likely to Diagram 1: Surgically remediable epilepsy - causes and classification. demonstrate psychic, emotional or other affective phenomena. Frontal epileptics are more likely to exhibit a rapid onset and offset and are more likely to occur nocturnally than other partial seizures. The automatisms of frontal lobe are of a “forced nature” These collectively stand in particular contrast to temporal lobe seizures. Frontal seizures can be classified anatomically into the following types. Fronto-polar seizures: Origins are often from scars following head injuries. They have the greatest likelihood of simply being characterized by what appear clinically to be primary generalized seizures. They may have some of the general characteristics of FLE, especially contralateral head deviation. Orbitofrontal seizures: These patients may have a semiology that mimics temporal lobe seizures in which case the origin is usually attributed to the posterior part of the orbital cortex. Once again, Diagram 2: Showing him various surgical options for intractable epilepsy. however, it may involve, in various combinations, other frontal lobe Seizure semiology: Clinical semiology is often divided into semiology, especially contralateral head and eye deviation. temporal and extratemporal epilepsy. Of the extratemporal group, the Premotor seizures: The epileptiform area includes the frontal lobe stands out as the next most common and diverse group Supplementary Motor Area (SMA) Prominent leg movements as far as seizures are concerned. We have highlighted the important favour involvement of the supplementary motor area. Head and eye clinical features of both below. deviation with varying bilateral tonic posturing are the commonest Temporal lobe seizures: These consist of unilateral dystonia seizure. When the deviation occurs at the onset of the seizure when posturing of an arm is classical of contralateral temporal lobe consciousness is intact it has significant localizing value to the contra epilepsy. Ipsilateral upper arm automatism, postictal coughing with lateral frontal cortex. Those seizures arising in the mid part of the olfactory auras which are poorly recognizable and associated with frontal lobe have a prominent bilateral tonic posturing. Bipedal an unpleasant foul smell (“uncal” or “uncinate” fits). Fear is another automatisms may take the form of symmetric bicycling or kicking limbic aura considered to be amygdaloid in origin. movements. Patients with left temporal lobe seizures cannot read normally The so-called “fencing posture” is classically associated with postictally. These are associated post-ictal dysphasia, behavioral the contralateral FL, particularly the SMA. This complex posture is aggression, sexual features, fetishes, and hypergraphia. characterized by abduction, external rotation, and partial flexion of Diagram 3: Showing phase I and II investigations for epilepsy surgery. © 2020 - Medtext Publications. All Rights Reserved. 017 2020 | Volume 1 | Article 1008 Clinics in Neurology Table 1: Differences between frontal and temporal seizures. the contralateral arm at the shoulder, contralateral deviation of the Features Frontal Lobe Temporal Lobe head and eyes such that they “look at” the contralateral arm, extended Seizure Frequency Frequent often daily Less Common ipsilateral arm downwards and backwards, and with the feet apart so Seizure onset Aburt. Explosive Slower as to support the partially contralaterally rotated trunk. Occasionally, Progression Rapid Slower the upper limb is also flexed at the elbow with the hand raised to Intial Motionlss Less Common Common the face that has turned forcefully towards it. There is occasionally Starting More Common and guttural, ill-understood speech. Automatism Less Common Longer Dominant opercular