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Chirurgische Epilepsietherapie

Surgical treatment for epilepsy

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Zusammenfassung

Chirurgische Maßnahmen zur Behandlung schwerer Epilepsien haben inzwischen weite Verbreitung und allgemeine Akzeptanz gefunden. Unterschiedliche Vorgehensweisen reflektieren einerseits die verschiedenen pathologischen und pathophysiologischen Gegebenheiten, andererseits auch unterschiedliche epileptologische und operative Konzepte.

Bei temporalen Eingriffen liegen keine homogenen Daten dafür vor, dass der Erhalt lateraler neokortikaler Strukturen für die kognitiven Funktionen vorteilhaft ist, ebensowenig, dass bei temporomesialen Epilepsien eine laterale oder auch eine ausgedehnte hippokampale Resektion zur Anfallskontrolle notwendig ist. Extratemporale Eingriffe machen in aller Regel eine umfassende prächirurgische Epilepsiediagnostik erforderlich, können jedoch mit Verfügbarkeit moderner Techniken wie funktionelle Bildgebung, Traktographie, Neuronavigation sowie intraoperativem Mapping und Monitoring erfolgreich durchgeführt werden. Die Hemisphärektomie/Hemisphärotomie stellt eine exzellente therapeutische Option für Patienten mit katastrophal verlaufenden Epilepsien unilateraler Genese dar. Unter den funktionellen Verfahren haben Stimulationstechniken in jüngster Zeit vermehrtes Interesse gefunden, während die Kallosotomie einen gewissen Stellenwert zur Behandlung schwerer Sturzanfälle beibehalten hat. Multiple subpiale Transsektionen werden fast ausschließlich nur noch in Ergänzung zur Resektion eingesetzt.

Das epilepsiechirurgische Programm hat sich insgesamt als erfolgreich erwiesen. Nach wie vor stehen die klassischen resektiven Verfahren im Vordergrund operativer Maßnahmen, wobei inzwischen ein klarer Trend zur Behandlung von Kindern und Jugendlichen zu erkennen ist.

Abstract

Surgical procedures to treat severe epilepsies have gained wide distribution and general acceptance. Different approaches reflect not only different pathologies and pathophysiologies, but also the history of epileptological and surgical concepts.

In temporal procedures, no homogenous data are available indicating that preservation of lateral neocortical structures is advantageous with respect to neurocognitive functions, nor that in temporomesial epilepsies lateral or extended hippocampal resection may be necessary for seizure control. Extratemporal procedures usually require extensive presurgical diagnostics, but can be successfully performed using modern techniques, including functional imaging, tractography, neuronavigation as well as intraoperative mapping and monitoring. Hemispherectomy/hemispherotomy constitutes an excellent therapeutic option for patients suffering from disastrous epilepsy with unilateral epileptogenesis. Amongst functional methods, stimulation techniques have recently gained increasing interest, while callosotomy has maintained its certain importance in the treatment of severe drop attacks. Multiple subpial transsections are almost exclusively used in addition to resection.

Overall, epilepsy surgery has proven to be successful. Classic resective procedures still continue to be performed most frequently. However, during the last two decades a clear trend toward the treatment of children and adolescents has been observed.

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    Josef Zentner

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Zentner, J. Chirurgische Epilepsietherapie. Z. Epileptol. 29, 115–129 (2016). https://doi.org/10.1007/s10309-016-0054-5

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