- Email: [email protected]
Surgery for Temporal Lobe Epilepsy
1115
Surgery for Temporal Lobe Epilepsy How many Lancet readers are aware of the resurgence of interest in surgical treatment of temporal lobe epilepsy in the past few years?l,2 Epilepsy surgery is, of course, not new; one of the very
first neurosurgical operations ever was for epilepsy. In 1886, Victor Horsley, who only 29 years of age but already FRS, carried out a cortical resection and excision of scar on James B, at the National Hospital for the Paralysed and Epileptic, Queen Square.3 James B was a patient of Hughlings Jackson and David Ferrier, and had recurrent episodes of status epilepticus following an open head injury. His condition was alleviated by this operation (at least for the 2 months of published follow-up), and Horsley presented James B and two other epilepsy cases at the annual meeting in Brighton of the British Medical Association, with Jackson, Charcot from Paris, and Thurling from Brooklyn among the audience. Medical meetings today can seldom be of such moment, and Horsley’s paper caused great excitement, as the published discussions show.4 Neurosurgery was now firmly on the map, and great hopes for epilepsy were raised. 60 more years were to pass, however, before a specific surgical therapy for temporal lobe epilepsy was introduced; and this was possible only with the widespread introduction of electroencephalography (EEG) in the early 1940s. Anterior temporal lobectomy was a technique first devised by Wilder Penfield in Montreal; fragments of temporal lobe tissue were removed by suction.5 The operation was soon modified by Murray Falconer, neurosurgeon at the Maudsley Hospital in London, who in the late 1940s developed the en bloc resection which has proved of
such value over the ensuing 30 years.6 Between 1950 and 1975 Falconer carried out 249 anterior lobectomies, and this legendary case-series has become a hallmark in the history of epilepsy. The 31st Maudsley monograph, published this year,’ reviews the clinical and neuropathological findings of these cases, and is testament to a magnificent achievement. After long-term follow-up, 68% of Falconer’s patients were greatly improved (seizure-free or occasional seizures), and the en bloc anterior temporal lobectomy remains a standard approach to the surgical treatment for temporal lobe epilepsy. In the past decade, however, important developments in the investigation of partial epilepsy, have opened the door to new surgical approaches. The most immediately practical advances have been in EEG technology; with the introduction of video-EEG telemetry, specialised electrode placements, and automated EEG analysis, the detailed EEG recording of actual epileptic seizures is now routine, and so complex patterns of spread of epileptic discharges can be defmed much more accurately.8 Other investigations of great promise are magnetoencephalography, which measures the magnetic changes in epileptic circuits; functional imaging studies, especially of receptor activity;9 and magnetic resonance imaging.10 These refinements in presurgical evaluation have led o new operative procedures, notably the amygdalo-hippocampectomy devised by Wieser and Yasargil in Zurich." This microsurgical technique carries the theoretical advantage that only small amounts of cerebral tissue are resected, thereby avoiding the psychometric consequences of the more extensive anterior temporaral lobectomy. The early results are encouraging, with the Zurich group reporting an excellent outcome in over 90% of operated cases. At the other extreme is the hemispherectomy, lately modified by Adams12 in Oxford to avoid postoperative complications, which is increasingly used in intractable epilepsy with infantile hemiplegia. Improvements in investigations and in surgical technique have also led to new non-resective surgical procedures, including the multiple subpial
6. Falconer MA. The surgical treatment of temporal lobe epilepsy Neurochriurgia 1965, 8: 160-72. 7 Bruton CJ The neuropathology of temporal lobe epilepsy Maudsley monograph 31. Oxford: Oxford University Press, 1988. 8 Gotman J, Ives JR, Gloor P, eds Long-term monitoring in epilepsy. Electroencephalog Clin Neurophysiol 1985 (EEG suppl 37) 9. Savic I, Persson A, Roland P, Pauli S, Sedvall G, Widén L In-vivo demonstration of reduced benzodiazepine receptor binding in human epileptic foci Lancet 1988; ii
863-66 1 Engel J, ed. Sungcal treatment of the epilepsies. New York: 2. Wieser HG, Elger CE, eds. Presurgical evaluation of
Raven, 1986. epileptics. Berlin: Springer-
Verlag,
1987.
3. Taylor D. One hundred years of
epilepsy surgery. J Neurol NeurosurgPsychiatry 1986;
49: 485-88. 4
Horsley V Brain-surgery. Br Med J 1868: 670-75. 5. Penfield W, Flanigin H. Surgical therapy of temporal Psychiatry 1950; 64: 491-500.
lobe seizures. Arch Neurol
10
Sperling MR, Sutherling WW, Nuwer MR New techniques for evaluating patients for epilepsy surgery. In: Engel J, ed Surgical treatment of the epilepsies New
York. Raven, 1986. 235-58. 11. Wieser HG. Selective amygdalo-hippocampectomy indications, inv estigative techniques and results. In Symon L, ed. Advances and technical standards in neurosurgery, vol 13. Vienna Springer-Verlag, 1985: 39-133. 12 Beardsworth E, Adams CBT. Modified hemispherectomy for epilepsy Br J Neurosurg 1988; 2: 73-84
1116
transections of Morrell,13 and the corpus callosum section. 14 Initial enthusiasm for corpus callosum section was tempered by serious operative technical problems and
by the dangers of rather lurid neuropsychological sequelae. More recently, modified techniques have been introduced, which are both surgically and cerebrally safer, and the operation is gaining popularity. How the division of the interhemispheric connections can improve partial seizures is unclear: the EEG evidence of bihemispheric epilepsy is often unchanged, despite considerable clinical improvement. Better understanding of the neuronal circuits underlying epilepsy holds great promise, not much for resective surgery, but for functional stereotactic surgery, in which the approach is to interrupt epileptic pathways rather than resect epileptic foci. Stereotaxis for epilepsy has been used on and off for some years, and lesions have been made in various cerebral structures, including the fields of
psychologists, neuroradiologists, and neurophysiologists are often required-eg, EEG monitoring to record actual seizures, and detailed imaging studies and psychometric assessment including amytal testing. Such facilities can be organised only on a supraregional basis, and a recent neurosurgeons,
estimate was that there should be 2 units in the UK and 8 in Europe with facilities to evaluate difficult cases.17 The organisational problem is fundamentally one of specialisation-a principle in neurology which in general has not been fully accepted,18 and the resource implications of which have not been fully addressed.
so
Forel, thalamus, putamen, subthalamic nuclei, mesencephalic reticular formation, and substantia nigra.1s None of these techniques has proved efficacious enough for widespread use, and this is perhaps not surprising, since they were devised on an essentially empirical rather than a neurophysiological basis; with better understanding of the neuronal circuits underlying epileptic seizures, the stereotactic interruption of these pathways becomes feasible. Strategically placed surgical lesions, pharmacological implants, or even focused radiotherapy are all possible approaches; and it may be that eventually functional stereotactic neurosurgery will largely supercede resective surgery. Of the 350 000 patients with chronic epilepsy in the UK, about two-thirds have partial epilepsy, and in about 20% of these seizure frequency exceeds one a week.16 Thus, over 40 000 patients exist whose focal epilepsy is wholly out of control. 5 % more than 2000 cases-at a conservative estimate might be suitable candidates for conventional temporal lobectomy, yet the number of patients who undergo surgery remains small. Moreover, the newer operative techniques may well widen surgical indications to encompass a greater proportion of cases. A major reason for the small number of patients receiving treatment is the specialised nature of the pre-surgical evaluation. To select suitable patients for temporal lobectomy, the combined efforts of neurologists,
F, Whistler WW. Multiple subpial transections: update and evaluation. In: Advances in epileptology Proceedings of the 17th Epilepsy International Congress Jerusalem, September, 1987. New York Raven (in press). 14 Spencer SS Corpus callosotomy in the treatment of intractable seizures. In Pedley TA, Meldrum BF, eds Recent advances in epilepsy, vol 4. London: Churchill Livingstone, 1988 181-204. 15 Spencer DD. Postscript: should there be a surgical treatment of choice and, if so, how should it be determined In: Engel J, ed Surgical treatment of the epilepsies. New York Raven, 1986 477-84. 16 Shorvon SD Medical services for epilepsy. In: Richens A, Laidlaw J, Oxley J, eds. A textbook of epilepsy 3rd ed London. Churchill Livingstone, 1988. 611-30.
13 Morrell
Of Pancreas, Pain, and
Papilla
AUTHORITIES vary in the extent to which they believe that treatment of chronic pancreatitis may be tailored to individual characteristics such as presence, site, and extent (or absence) of pancreatic duct
dilatation,l-4 alcoholic aetiology,5 or pathological severity.3,5,6 Drainage operations2,6,’ in particular have been criticised on the grounds that results are
unpredictable and
at best short-lived. The one situation in which there is a measure of concordance is the congenital abnormality of pancreas divisum.
Endoscopic sphincterotomy8,9 or surgical sphincteroplasty10,11 of the accessory duct of Santorini improves a small but useful proportion of symptomatic patients for whom total pancreatectomy is probably the only effective alternative.5 The sphincter of Oddi comprises interconnected annular sphincters of the common papilla, bileduct, and pancreatic duct, but anatomical variation is common and separate manometric evaluation of the components and of their differential functional activity remains contentious.12 Tight stenosis of the duodenal pancreatico-biliary papilla might reasonably 17.
Janz D. Consequences for the present practice of epilepsy therapy in Europe. Wieser HG, Elger CE, eds. Presurgical evaluation of epileptics Berlin Springer-Verlag,
1987: 373-77 18. Shorvon SD Specialised services for the non-institutionalised patients with epilepsy developments in the US and UK. Health Trends 1983; 15: 40-45 1 Cooper MJ, Williamson RCN. Drainage operations in chronic pancreatitis Br J Surg
1984, 71: 761-66. Pancreaticogastrostomy. the preferred operation for pain relief in chronic pancreatitis. Br JSurg 1988; 75: 220-22 3 Mannell A, Adson MA, Mcllrath DC, Ilstrup DM Surgical management of chronic pancreatitis: long-term results in 141 patients Br JSurg 1988; 75: 467-72 4. Shankar S, Russell RCG Distal pancreatic resection in benign pancreatic disease Gut
2. Pain JA, Knight MJ.
1988; 29: A1458. 5. Linehan IP, Lambert MA, Brown DC, Kurtz AB, Cotton PB, Russell RCG. Total pancreatectomy for chronic pancreatitis. Gut 1988, 29: 358-65. 6. Bagley FH, Braasch JW, Taylor RH, Warren KW Sphincterotomy or sphincteroplasty in the treatment of pathologically mild chronic pancreatitis Am J Surg 1981; 141: 418-22 7. Partington PF, Rochelle REL. Modified Puestow procedure for retrograde drainage of the pancreatic duct Ann Surg 1960; 152: 1037-43. 8 Cotton PB Pancreatic orifice sphincterotomy, expenence from 15 centres. Gut 1983; 24: A967. 9. Lehman G, Hawes R, O’Connor K Endoscopic drainage procedures on the minor papilla for symptomatic pancreas divisum. Gastrointest Endosc 1988, 34: 190 10 Russell RCG. Accessory sphincterotomy (endoscopic and surgical m patients with pancreas divisum Br J Surg 1984, 71: 954-57. 11. Linehan IP, Russell RCG Follow up of accessory sphincteroplasty for chronic pancreatitis associated with pancreas divisum. Gut 1987, 28: A368. 12 Gregg JA, Carr-Locke DL. Endoscopic pancreatic and biliary manometry in pancreatic, biliary and papillary disease and after endoscopic sphincterotomy and surgical sphincteroplasty. Gut 1984; 25: 1247-54.
Surgery for Temporal Lobe Epilepsy How many Lancet readers are aware of the resurgence of interest in surgical treatment of temporal lobe epilepsy in the past few years?l,2 Epilepsy surgery is, of course, not new; one of the very
first neurosurgical operations ever was for epilepsy. In 1886, Victor Horsley, who only 29 years of age but already FRS, carried out a cortical resection and excision of scar on James B, at the National Hospital for the Paralysed and Epileptic, Queen Square.3 James B was a patient of Hughlings Jackson and David Ferrier, and had recurrent episodes of status epilepticus following an open head injury. His condition was alleviated by this operation (at least for the 2 months of published follow-up), and Horsley presented James B and two other epilepsy cases at the annual meeting in Brighton of the British Medical Association, with Jackson, Charcot from Paris, and Thurling from Brooklyn among the audience. Medical meetings today can seldom be of such moment, and Horsley’s paper caused great excitement, as the published discussions show.4 Neurosurgery was now firmly on the map, and great hopes for epilepsy were raised. 60 more years were to pass, however, before a specific surgical therapy for temporal lobe epilepsy was introduced; and this was possible only with the widespread introduction of electroencephalography (EEG) in the early 1940s. Anterior temporal lobectomy was a technique first devised by Wilder Penfield in Montreal; fragments of temporal lobe tissue were removed by suction.5 The operation was soon modified by Murray Falconer, neurosurgeon at the Maudsley Hospital in London, who in the late 1940s developed the en bloc resection which has proved of
such value over the ensuing 30 years.6 Between 1950 and 1975 Falconer carried out 249 anterior lobectomies, and this legendary case-series has become a hallmark in the history of epilepsy. The 31st Maudsley monograph, published this year,’ reviews the clinical and neuropathological findings of these cases, and is testament to a magnificent achievement. After long-term follow-up, 68% of Falconer’s patients were greatly improved (seizure-free or occasional seizures), and the en bloc anterior temporal lobectomy remains a standard approach to the surgical treatment for temporal lobe epilepsy. In the past decade, however, important developments in the investigation of partial epilepsy, have opened the door to new surgical approaches. The most immediately practical advances have been in EEG technology; with the introduction of video-EEG telemetry, specialised electrode placements, and automated EEG analysis, the detailed EEG recording of actual epileptic seizures is now routine, and so complex patterns of spread of epileptic discharges can be defmed much more accurately.8 Other investigations of great promise are magnetoencephalography, which measures the magnetic changes in epileptic circuits; functional imaging studies, especially of receptor activity;9 and magnetic resonance imaging.10 These refinements in presurgical evaluation have led o new operative procedures, notably the amygdalo-hippocampectomy devised by Wieser and Yasargil in Zurich." This microsurgical technique carries the theoretical advantage that only small amounts of cerebral tissue are resected, thereby avoiding the psychometric consequences of the more extensive anterior temporaral lobectomy. The early results are encouraging, with the Zurich group reporting an excellent outcome in over 90% of operated cases. At the other extreme is the hemispherectomy, lately modified by Adams12 in Oxford to avoid postoperative complications, which is increasingly used in intractable epilepsy with infantile hemiplegia. Improvements in investigations and in surgical technique have also led to new non-resective surgical procedures, including the multiple subpial
6. Falconer MA. The surgical treatment of temporal lobe epilepsy Neurochriurgia 1965, 8: 160-72. 7 Bruton CJ The neuropathology of temporal lobe epilepsy Maudsley monograph 31. Oxford: Oxford University Press, 1988. 8 Gotman J, Ives JR, Gloor P, eds Long-term monitoring in epilepsy. Electroencephalog Clin Neurophysiol 1985 (EEG suppl 37) 9. Savic I, Persson A, Roland P, Pauli S, Sedvall G, Widén L In-vivo demonstration of reduced benzodiazepine receptor binding in human epileptic foci Lancet 1988; ii
863-66 1 Engel J, ed. Sungcal treatment of the epilepsies. New York: 2. Wieser HG, Elger CE, eds. Presurgical evaluation of
Raven, 1986. epileptics. Berlin: Springer-
Verlag,
1987.
3. Taylor D. One hundred years of
epilepsy surgery. J Neurol NeurosurgPsychiatry 1986;
49: 485-88. 4
Horsley V Brain-surgery. Br Med J 1868: 670-75. 5. Penfield W, Flanigin H. Surgical therapy of temporal Psychiatry 1950; 64: 491-500.
lobe seizures. Arch Neurol
10
Sperling MR, Sutherling WW, Nuwer MR New techniques for evaluating patients for epilepsy surgery. In: Engel J, ed Surgical treatment of the epilepsies New
York. Raven, 1986. 235-58. 11. Wieser HG. Selective amygdalo-hippocampectomy indications, inv estigative techniques and results. In Symon L, ed. Advances and technical standards in neurosurgery, vol 13. Vienna Springer-Verlag, 1985: 39-133. 12 Beardsworth E, Adams CBT. Modified hemispherectomy for epilepsy Br J Neurosurg 1988; 2: 73-84
1116
transections of Morrell,13 and the corpus callosum section. 14 Initial enthusiasm for corpus callosum section was tempered by serious operative technical problems and
by the dangers of rather lurid neuropsychological sequelae. More recently, modified techniques have been introduced, which are both surgically and cerebrally safer, and the operation is gaining popularity. How the division of the interhemispheric connections can improve partial seizures is unclear: the EEG evidence of bihemispheric epilepsy is often unchanged, despite considerable clinical improvement. Better understanding of the neuronal circuits underlying epilepsy holds great promise, not much for resective surgery, but for functional stereotactic surgery, in which the approach is to interrupt epileptic pathways rather than resect epileptic foci. Stereotaxis for epilepsy has been used on and off for some years, and lesions have been made in various cerebral structures, including the fields of
psychologists, neuroradiologists, and neurophysiologists are often required-eg, EEG monitoring to record actual seizures, and detailed imaging studies and psychometric assessment including amytal testing. Such facilities can be organised only on a supraregional basis, and a recent neurosurgeons,
estimate was that there should be 2 units in the UK and 8 in Europe with facilities to evaluate difficult cases.17 The organisational problem is fundamentally one of specialisation-a principle in neurology which in general has not been fully accepted,18 and the resource implications of which have not been fully addressed.
so
Forel, thalamus, putamen, subthalamic nuclei, mesencephalic reticular formation, and substantia nigra.1s None of these techniques has proved efficacious enough for widespread use, and this is perhaps not surprising, since they were devised on an essentially empirical rather than a neurophysiological basis; with better understanding of the neuronal circuits underlying epileptic seizures, the stereotactic interruption of these pathways becomes feasible. Strategically placed surgical lesions, pharmacological implants, or even focused radiotherapy are all possible approaches; and it may be that eventually functional stereotactic neurosurgery will largely supercede resective surgery. Of the 350 000 patients with chronic epilepsy in the UK, about two-thirds have partial epilepsy, and in about 20% of these seizure frequency exceeds one a week.16 Thus, over 40 000 patients exist whose focal epilepsy is wholly out of control. 5 % more than 2000 cases-at a conservative estimate might be suitable candidates for conventional temporal lobectomy, yet the number of patients who undergo surgery remains small. Moreover, the newer operative techniques may well widen surgical indications to encompass a greater proportion of cases. A major reason for the small number of patients receiving treatment is the specialised nature of the pre-surgical evaluation. To select suitable patients for temporal lobectomy, the combined efforts of neurologists,
F, Whistler WW. Multiple subpial transections: update and evaluation. In: Advances in epileptology Proceedings of the 17th Epilepsy International Congress Jerusalem, September, 1987. New York Raven (in press). 14 Spencer SS Corpus callosotomy in the treatment of intractable seizures. In Pedley TA, Meldrum BF, eds Recent advances in epilepsy, vol 4. London: Churchill Livingstone, 1988 181-204. 15 Spencer DD. Postscript: should there be a surgical treatment of choice and, if so, how should it be determined In: Engel J, ed Surgical treatment of the epilepsies. New York Raven, 1986 477-84. 16 Shorvon SD Medical services for epilepsy. In: Richens A, Laidlaw J, Oxley J, eds. A textbook of epilepsy 3rd ed London. Churchill Livingstone, 1988. 611-30.
13 Morrell
Of Pancreas, Pain, and
Papilla
AUTHORITIES vary in the extent to which they believe that treatment of chronic pancreatitis may be tailored to individual characteristics such as presence, site, and extent (or absence) of pancreatic duct
dilatation,l-4 alcoholic aetiology,5 or pathological severity.3,5,6 Drainage operations2,6,’ in particular have been criticised on the grounds that results are
unpredictable and
at best short-lived. The one situation in which there is a measure of concordance is the congenital abnormality of pancreas divisum.
Endoscopic sphincterotomy8,9 or surgical sphincteroplasty10,11 of the accessory duct of Santorini improves a small but useful proportion of symptomatic patients for whom total pancreatectomy is probably the only effective alternative.5 The sphincter of Oddi comprises interconnected annular sphincters of the common papilla, bileduct, and pancreatic duct, but anatomical variation is common and separate manometric evaluation of the components and of their differential functional activity remains contentious.12 Tight stenosis of the duodenal pancreatico-biliary papilla might reasonably 17.
Janz D. Consequences for the present practice of epilepsy therapy in Europe. Wieser HG, Elger CE, eds. Presurgical evaluation of epileptics Berlin Springer-Verlag,
1987: 373-77 18. Shorvon SD Specialised services for the non-institutionalised patients with epilepsy developments in the US and UK. Health Trends 1983; 15: 40-45 1 Cooper MJ, Williamson RCN. Drainage operations in chronic pancreatitis Br J Surg
1984, 71: 761-66. Pancreaticogastrostomy. the preferred operation for pain relief in chronic pancreatitis. Br JSurg 1988; 75: 220-22 3 Mannell A, Adson MA, Mcllrath DC, Ilstrup DM Surgical management of chronic pancreatitis: long-term results in 141 patients Br JSurg 1988; 75: 467-72 4. Shankar S, Russell RCG Distal pancreatic resection in benign pancreatic disease Gut
2. Pain JA, Knight MJ.
1988; 29: A1458. 5. Linehan IP, Lambert MA, Brown DC, Kurtz AB, Cotton PB, Russell RCG. Total pancreatectomy for chronic pancreatitis. Gut 1988, 29: 358-65. 6. Bagley FH, Braasch JW, Taylor RH, Warren KW Sphincterotomy or sphincteroplasty in the treatment of pathologically mild chronic pancreatitis Am J Surg 1981; 141: 418-22 7. Partington PF, Rochelle REL. Modified Puestow procedure for retrograde drainage of the pancreatic duct Ann Surg 1960; 152: 1037-43. 8 Cotton PB Pancreatic orifice sphincterotomy, expenence from 15 centres. Gut 1983; 24: A967. 9. Lehman G, Hawes R, O’Connor K Endoscopic drainage procedures on the minor papilla for symptomatic pancreas divisum. Gastrointest Endosc 1988, 34: 190 10 Russell RCG. Accessory sphincterotomy (endoscopic and surgical m patients with pancreas divisum Br J Surg 1984, 71: 954-57. 11. Linehan IP, Russell RCG Follow up of accessory sphincteroplasty for chronic pancreatitis associated with pancreas divisum. Gut 1987, 28: A368. 12 Gregg JA, Carr-Locke DL. Endoscopic pancreatic and biliary manometry in pancreatic, biliary and papillary disease and after endoscopic sphincterotomy and surgical sphincteroplasty. Gut 1984; 25: 1247-54.