Surgery for epilepsy

Despite important advances in the treatment of epilepsy over the past several decades, many patients remain uncontrolled. Partial complex (psychomotor) seizures are the largest problem, with less than two thirds of patients successfully managed despite optimal medication use. In these situations, various surgical procedures may be helpful, depending on the type of epilepsy, its cerebral location of origin, and the neurologic status of the particular patient. Intensive investigation including EEG and audiovisual monitoring are utilized to evaluate the medically refractory epileptic. In some instances, specialized recordings from epidural, subdural or intracerebral locations are needed to try to pinpoint onset of focal seizure. When this is possible, and the epileptogenic area is resectable, cortical excision may provide cure or marked reduction of seizures in 60 to 90 per cent of properly selected patients with minimal morbidity. The most common operation is temporal lobectomy; this procedure itself is undergoing modifications as more is learned about the usual locations of seizure foci and the functions of this tissue. Resections in other cortical areas may be more difficult but are possible. When a single focus is not identified or is not resectable, other procedures may be used. Results in seizure control with chronic cerebellar stimulation have been variable. The results of stereotaxic lesions in various locations are difficult to evaluate with the single exception of field H of Forel, which in many reports has been effective for grand mal seizures. Generalized seizures, particularly in patients with infantile hemiplegia or frontal lobe epilepsy, are well controlled with corpus callosotomy. Surgery for epilepsy is currently practiced at several centers in this country and abroad. There is great need for more such centers and more education about this treatment as estimates indicate 100,000 patients in the United States at this time could benefit from such procedures.