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Surgical Tools and Techniques

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Surgical Treatment of Epilepsies

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Abstract

Current neurosurgery is best characterized by the terms functionally oriented and functionally guided surgery. Microsurgical techniques facilitate neurosurgical interventions in most brain regions with calculable risks. The technique of subpial gyral emptying has proven to be useful in highly vascularized areas where traversing vascular structures must be left intact to avoid infarctions in distant territories. Fused structural and functional imaging data can be made available for the neurosurgeon by neuronavigation both for planning the approach and for setting boundaries of resection. It is advisable to address any critical target early during surgery prior to brain shift effects. Real-time guidance of surgery by intraoperative imaging may only be useful in selected cases, e.g., to delineate subtle lesions such as focal cortical dysplasias in extratemporal location. For presurgical mapping, noninvasive techniques such as fMRI are available. Stimulation mapping to define language areas can be performed extraoperatively requiring a second procedure for resection, or intraoperatively during awake surgery. Mapping of the central area as well as of the pyramidal tract is feasible in general anesthesia with electrophysiological techniques. Somatosensory and motor evoked potentials have proven to be useful tools for intraoperative monitoring of the central area as well as ascending and descending pathways, and both modalities provide complementary information. With all these tools available, it should be emphasized that functional anatomy remains the essential basis for all neurosurgical interventions.

The brain is the organ of destiny. It holds within its humming mechanism secrets that will determine the future of the human race.

Wilder Penfield

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Zentner, J. (2020). Surgical Tools and Techniques. In: Surgical Treatment of Epilepsies. Springer, Cham. https://doi.org/10.1007/978-3-030-48748-5_4

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