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Presurgical Evaluation

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Surgical Treatment of Epilepsies

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Abstract

The selection of appropriate candidates for surgical treatment requires comprehensive evaluation. It has to be confirmed that seizures fulfill the criteria of drug resistance, that the patient has been adequately treated, and that non-epileptic disorders are ruled out. The essential prerequisite for a resective surgical procedure is the evidence that seizures arise in a circumscribed area, known as the epileptogenic zone, and that this area can be resected without harm. Presurgical evaluation aims at the definition of the epileptogenic zone, removal of which per definition leads to seizure freedom. It is based on clinical, neuropsychological, and psychiatric assessment, neuroimaging, and electrophysiological diagnostics. MRI providing evidence of the structural basis of focal epilepsy has proven to be the key diagnostic tool guiding the surgeon, and removal of the structural abnormality has been shown to be the most important prognostic factor for postoperative seizure freedom. In addition to the definition of the epileptogenic area, presurgical assessment has to evaluate the chances of controlling seizures and improve the patient’s quality of life with surgery. Risks of surgery, especially regarding cognitive functions, have to be weighed up against the risks associated with continuous medical treatment. Progress of diagnostic workup is discussed in regular intervals in the interdisciplinary epilepsy conference consisting of a core team of epileptologists, neuropsychologists, neuropsychiatrists, neuroradiologists, EEG technicians, and neurosurgeons. Having reached consensus, the team formulates a detailed plan to proceed. When all presurgical information points to a unifying location, i.e., when data from clinical, neuropsychological, and electrophysiological studies as well as from imaging modalities are congruent, the patient can proceed to surgical treatment.

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

William Osler

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Zentner, J. (2020). Presurgical Evaluation. In: Surgical Treatment of Epilepsies. Springer, Cham. https://doi.org/10.1007/978-3-030-48748-5_3

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