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Extratemporal Resections

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Surgical Treatment of Epilepsies

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Abstract

Extratemporal epilepsies (ETE) show a large variety of clinical syndromes. Variable seizure semiology can be attributed to rapid propagation of ictal activity in a widespread network including projections to the contralateral side, thus rendering detection of respective seizure foci by clinical and electrophysiological assessment extremely difficult. Further problems restricting surgical treatment of ETE refer to the involvement of eloquent cortical areas including Broca’s area, supplementary motor area (SMA), Rolandic cortex (pre- and postcentral gyrus), insula, and visual cortex. For resections in the frontal operculum around Broca’s area, the technique of subpial gyral emptying should be used in order to prevent ischemic events in more distant areas. The SMA can be removed completely without disadvantage in the long run, since the SMA deficiency syndrome can be expected to recover almost completely over a period of around 3 weeks. The basal aspects of the precentral and postcentral gyri representing the motor and sensory face and tongue area can be resected up to the hand area (maximum roughly 6 cm above the Sylvian fissure) without permanent harm. All insular pathologies can be reached by the transopercular route, while for pure insular lesions and pathologies extending to the temporomesial area, the transsylvian approach seems to be ideal. As a result of the wide dispersion of the optic radiation, already superficial resections particularly at the mesial aspects of the occipital lobe are frequently associated with visual field deficits. Due to these obstacles, results of extratemporal resections reported in the past are not as favorable as temporal procedures. Advances in MR imaging facilitating detection of the structural basis of ETE and pointing to the epileptogenic zone have decisively changed this situation. Overall, results of extratemporal resections have noticeably improved over time approximating or even exceeding now those obtained with temporal procedures. In fact, the success of epilepsy surgery over the last years has particularly become apparent in the treatment of extratemporal epilepsies, while outcomes achieved with temporal procedures remained stable over the last decades.

There is no end to education. It is not that you read a book, pass an examination, and finish with education. The whole of life, from the moment you are born to the moment you die, is a process of learning.

Jiddu Krishnamurti

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Zentner, J. (2020). Extratemporal Resections. In: Surgical Treatment of Epilepsies. Springer, Cham. https://doi.org/10.1007/978-3-030-48748-5_7

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