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Although many patients with epilepsy achieve control of their seizures with medication, a substantial number ultimately develop intractable epilepsy. Patients with intractable epilepsy form the group for whom surgical procedures may be beneficial. We retrospectively analyzed the clinical profile and outcome of 141 patients operated for intractable epilepsy at Vellore between 1949 and 1990. The operative procedures done for suprasylvian epilepsy were topectomy (24 cases) and lobectomy (2 cases). For temporal lobe epilepsy the surgical procedures done were topectomy (28 cases), temporal lobectomy with amygdalectomy (25 cases), temporal lobectomy with amygdalectomy and hippocampectomy (10 cases), amygdalectomy (15 cases) and topectomy with amygdalectomy in one case. Hemispherectomy was done for 12 cases with multilobe epilepsy. For multifocal epilepsy, four patients underwent stereotactic ansotomy. Post operative complications included infections (10 cases) and acute post operative haematoma in one patient. There was transient neurological deterioration in ten patients. Three patients operated prior to 1960 died due to peri operative complications. Follow up data of 80 patients, ranging from 1 to 42 years (mean 10 years) was analysed. Total or near total seizure control was obtained in 53% patients and a worthwhile outcome in 20% patients. Mental retardation, pre operative scalp electroencephalography and post excision electrocorticography has been shown to be predictors of outcome with respect to seizures.
Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th-century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.
Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.
Twenty-four patients with intractable partial epilepsy underwent surgery between 1969 and 1988. Localization was by non-invasive means using scalp EEG and CT. In 12 cases the focus was temporal and in eight frontal. Craniotomy was undertaken with intraoperative electrocorticography (ECoG). Ten cases had a standard temporal lobectomy, seven a topectomy, four topectomy with tumour excision and one tumour excision alone. Two cases did not have a resection. Pathology revealed a mass lesion in 12 cases, hippocampal sclerosis in two and gliosis in six. Mean length of follow-up was 7.4 was. Fourteen patients (64%) were seizure free, two (9%) almost seizure free, four (18%) had worthwhile improvement and two (9%) no improvement. Of the temporal resections, 9 out of 12 (75%) were seizure free and of the extratemporal resections 5 out of 10 (50%) were seizure free. Removal of a mass lesion carried the most favourable prognosis for seizure outcome: 10 our of 12 (83%) of the cases with mass lesions, but 3 out of 6 (50%) of the cases with gliosis were seizure free. In two of the frontal resections removal of tumour resulted in disappearance of contralateral frontal independent spikes. It is concluded that where sufficient information exists to localize seizure activity by non-invasive means, invasive recording is unnecessary. The utility of intraoperative ECoG is discussed. It may be of limited use in cases of standard resection of when a mass lesion is present, but ECoG can prove useful to delineate the epileptogenic area in cases where there is o mass lesion and the results can still be rewarding.
The pre-requisite conditions for surgical treatment of epilepsy are: ineffective pharmacotherapy, the unacceptable nature of the seizures and the presence of an organic brain lesion as the basis of the disease. The principles of surgery stem from knowledge of the anatomicofunctional structure and evolution of the epileptic process, which indicate the targets for surgery. Two main groups of surgical approaches are available. The first and most efficient one aims at suppressing the seizures by acting on the nucleus of origin of the epilepsy; the combined removal of both the causative cerebral lesion and the primary epileptogenic zone is considered as the "optimal" type of surgery (hemispherectomy, lobectomy, topectomy); only in rare cases is an ablation limited either to the causative lesion (mainly in children) or to the epileptogenic zone sufficient. The second group of surgical procedures aims at reducing the cerebral epileptogenicity by preventing diffusion of the epileptic discharges (callosotomy, subpial transections), by enhancing inhibitory (cerebellar stimulation) or reducing facilitatory influences (stereotactic deep lesions); these are regarded as a "second choice" treatment. The final surgical indication, the choice of the surgical approach and the surgical prognosis are dependent on accurate presurgical investigations. The very good results which can be obtained should favour the wider use of surgery.
BACKGROUND: Patients with multilobar or bihemispheric seizure foci (MLBHSF) are generally not considered candidates for major resective surgery because of the high risk of complications. A combination of relatively less invasive surgical procedures were used to treat 19 patients with intractable seizures with MLBHSF. METHODS: Epileptogenic areas were identified via standard techniques. Locations of the seizure foci were in two lobes of a hemisphere in 11 patients, three lobes of a hemisphere in four patients, four lobes of a hemisphere in one patient, and both hemispheres in three patients. All 19 patients had multiple subpial transections; in addition, seven patients had small topectomies and nine patients had amygdala hippocampotomies. RESULTS: The longest follow-up is 54 months and the median for follow-up is 33 months. Nine patients (47%) are either free of seizures or have only rare seizures; eight patients (41%) have greater than 90% reduction in seizure frequency; one patient (6%) has complete cessation of myoclonic seizures and secondary generalization, and greater than 50% reduction in partial complex seizures; and one patient (6%) has greater than 50% reduction in seizure frequency. There were no permanent operative complications. CONCLUSION: Though the follow-up is relatively short and the number of patients is small, these results are encouraging, because the majority of patients in this group were poor surgical candidates.
Seventy patients with intractable epilepsy were surgically treated. Thirty-three patients underwent a stereotactic procedure and in all as a first-stage operation fornicotomy was performed. Because of inadequate results in 14 patients, an additional stereotactic intervention was necessary; the targets were amygdala, thalamus, and Forel's H-field, and the final outcome of these patients was 9 (27%) seizure-free, 19 (58%) improved, and 5 (15%) unchanged. In 3 patients a selective amygdalo-hippocampectomy was performed with 2 seizure-free patients and one with improvement. Topectomy in focal epilepsy in 5 patients resulted in freedom from seizures in all cases. In 23 patients a lobectomy was performed; 10 (43%) were seizures-free, 8 (35%) were improved, and 5 (22%) were unchanged. In 6 patients only a pathological lesion was resected. Our results speak in favour of ablative surgery. However, stereotactic operations are indicated in cases with secondary generalization and dissipated foci on the dominant hemisphere.
We have studied the effects of the ablation of the cerebellar vermal area corresponding to lobules VI - VIII and of the flocculus - paraflocculus of both sides on the spontaneous eye movements performed in the light and in the dark in head-restrained pigmented rats. These effects have been compared with those already described for the inferior olive lesion. The cerebellar lesions were performed 1 week to 6 months in advance. Eye movements were recorded through a phase detection search coil apparatus. Following vermal topectomy, the main characteristics of the spontaneous saccades are unmodified. Following the ablation of the flocculus - paraflocculus there is no change in the saccadic main sequence. However, the spontaneous saccades in the dark present a postsaccadic drift made up of two components with different time courses, the first one being fast and the second one slow. The former is due in part to a mismatch between the phasic (the pulse) and the tonic (the step) components of the eye movements; the latter to the leakage of the neural integrator. In light only the first component is present and the eye maintains a steady position. The time constant of the neural integrator is considerably reduced to approximately 600 - 900 ms from a value of approximately 1600 - 4000 ms in the intact rats. The amplitude of the postsaccadic drift in the light depends on both the mismatch between the pulse and the step of innervation of the extraocular muscles and the increased leakiness of the neural integrator. The gain of the pulse to step transformation is reduced to approximately 0.79 at all saccadic amplitudes and eccentricities and such a reduction is due to a decreased step amplitude, while the pulse amplitude remains unchanged. The contribution of the leakage of the neural integrator to the postsaccadic drift in the light is a function of the eccentricity with a slope of 0.23. The deficits described after flocculus - paraflocculus ablation are also very similar to those described following inferior olive lesion from a quantitative point of view. The possible mechanisms of the visually activated olivocerebellar system in the control of saccadic performance and in maintaining its calibration are discussed.
Long-term effects of topectomy showed statistically significant losses not present shortly after psychosurgery in eight of 14 psychological test measures. Site of operation, length of postoperative interval, age, and nature of the measure were factors determining the effects of brain damage.
Minimally invasive procedures (multiple subpial transection, topectomy and amygdalahippocampotomy) were used to treat 24 patients with intractable seizures. The seizure foci were in both hemispheres in 3 patients, all 4 lobes of a hemisphere in 1 patient, 3 lobes of a hemisphere in 5 patients, 2 lobes of a hemisphere in 11 patients and the temporal lobe alone in 4 patients. The longest follow-up is 41 months, with a median of 18 months. Sixteen patients have a follow-up of more than 1 years, with excellent results in 10 (66%) and good in the remaining 6 (38%). There were no permanent complications These results are encouraging, because the majority of the patients were poor candidates for surgery.
Magnetic resonance imaging (MRI) offers significant advantages over computerized tomography (CT) and teleradiographic techniques when used for the evaluation and management of epilepsy and functional neurological disorders. Depth recording and radiofrequency electrodes can be more accurately positioned within structures such as the amygdala and hippocampus. The extent of corpus callosum section, lobectomy, topectomy, and radiofrequency stereotactic lesions can now be readily confirmed and related with seizure, neurological, and behavioral outcome. Occult, usually low grade, intraparenchymal neoplasms not visualized on CT scans can be located by MRI and biopsied or excised by MRI stereotactic techniques.
A brief overview is given on the concepts and methods of presurgical evaluation, as well as on the principles and techniques of surgical treatment of epilepsies. Lesion-oriented surgery is differentiated from epilepsy-oriented lesional surgery and from surgery for epilepsy sensu stricto. The rationale for 'curative' and 'palliative' interventions is discussed. Selective amygdalohippocampectomy, anterior temporal lobe resection, extratemporal topectomies, subtotal functional hemispherectomies, stereotactic interventions, anterior corpus callosum section and multiple subpial transection are briefly described. Results of a survey done on the occasion of the 2nd International Palm Desert Conference on the 'Surgical Treatment of the Epilepsies' are summarized.
Functional hemispherectomy techniques have been designed to minimize the long-term complications of anatomical resection without reducing the effectiveness of seizure control. The authors have used an ultrasound-guided approach tailored to combine temporal lobectomy with frontal and occipital disconnections with a central topectomy of the lateral, insular, and interhemispheric cortex. This technique achieves a comprehensive functional disconnection and minimizes entrance and manipulation within the body of the lateral ventricle. Eight patients ranging in age from 10 months to 23 years with congenital paresis and medically intractable seizures underwent functional hemispherectomy via this technique. The average surgical time was 4.5 hours, and blood loss ranged from 90 to 400 ml. All but one patient was discharged after 5 days. Postoperative fever syndromes, aseptic meningitis, and infection were avoided. On long-term follow-up evaluation (range 18-60 months, mean 38 months), seven of eight patients remain seizure free and were not on a course of anticonvulsant agents. Advantages of this technique include avoiding entrance into the ventricle, a more predictable postoperative period, and reduced postoperative complications.
INTRODUCTION: Only few medically refractory epileptic patients are evaluated for surgical treatment, in spite of the good results obtained at the Centers where epilepsy surgery is performed. OBJECTIVE: We are presenting the way the Gregorio Marañón Hospital Epilepsy Surgery Unit functions and their casuistry. PATIENTS AND METHODS: This Unit is composed by members of the Services of Neurosurgery, Neurology, Neurophysiology, Neuroradiology, Psychology, Neuropediatry, Nuclear Medicine and Neuroanestesiology. Patients are studied by means of protocols. RESULTS: Twenty cases were operated upon. The procedures were temporal lobectomy in 9 cases, amygdalo-hipocampectomy in 4, frontal lobectomy in 3, frontal topectomy in 2, partial hemispherectomy in 1 and vagal nerve stimulation in 1. In 16 of the 19 surgery specimen there were some pathological abnormalities. In the short follow-up 13 patients are seizures free experience significant improvement.