Presurgical evaluation in epilepsy

-Principals and practice

 History

Hughling
Jackson
 Importance
Upto 60% of epilepsy have focal syndromes, out
of that 15% will not be well controlled with drugs.
50 % of this are surgical candidates.
4% of total epileptic require presurgical
evaluation.
Outcome of surgery in established epilepsy
centre is 60%.

 Presurgical evaluation in epilepsy .Brain 2001, Luders

Zones
 Epileptogenic zone – Region of cortex that generates
epileptic seizures. Total removal of this area is required
for seizure cure

 Symptomatic Zone – region of the cortex that generates

initial ictal symptoms.

 Irritative Zone – region of cortex that generates interictal

spikes on EEG/MEG.

 Ictal Onset zone- region of cortex of clinical seizure onset..

 Lesional Zone – lesion on neuroimaging

 Functional Deficit Zone – Area which have interictal

functional deficit on neurological/psychometric
evaluation.

 Eloquent cortex – Region of cortex that is

indispensible for defined cortical functions.
 Semiological seizure classification
Epileptic seizure Aura
Somatosensory aura Auditory aura, Olfactory aura, Abdominal aura,Visual
aura,Gustatory aura , Autonomic aura, Psychic aura
Autonomic seizures
Dialeptic seizure - Typical dialeptic seizure
Motor seizure
Simple motor seizure - Myoclonic seizure, Epileptic spasm, Tonic-clonic
seizure,Tonic seizure, Clonic seizure, Versive seizure.
Complex motor seizure- Hypermotor seizure, Automotor seizure,Gelastic
seizure
Special seizure
Atonic seizure, Astatic seizure ,Hypomotor seizure, Negative myoclonic
seizures, Akinetic seizure, Aphasic seizure
Paroxysmal event
Modifiers
Left/right/axial/generalized/bilateral asymmetric
 Seizure Semiology
Aura – Subjective sensation as described by patients
without objective evidence.
Somatosensory aura Visual aura

Auditory aura Gustatory aura

Olfactory aura Autonomic aura

Abdominal aura Psychic aura

Autonomic Seizures – Objective evidence of
autonomic dysfunction like heart rate change,
sweating, pupils.

Dialeptic Seizures – seizures in which prominent

features is loss of consciousness defined by loss
of responsiveness or loss of awareness.
Typical dialeptic seizure is transient loss of
awareness with 3hz discharge on EEG.
Motor seizures

- Simple motor seizure -simple, unnatural motor

movement elicited by stimulation of primary motor
cortex.
Myoclonic seizure Tonic seizure
Epileptic spasm Clonic seizure
Tonic-clonic seizure Versive seizure

- Complex motor seizure – copmlex mov, may be natural

but inappropriate for situation.
Hypermotor seizure Gelastic seizure
Automotor seizure
Hypermotor seizure – main manifestations
consist of complex movements involving the
proximal segments of the limbs and trunk, often
stereotyped/violent.

Automotor seizures – in which prominent feature

is automatism,usually with LOA , defined by distal
hand /feet or oral.
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Evaluation
Video EEG
MRI Brain
Ictal Spect
Interictal PET/Spect
Pschyometry
Functional MRI
 Invasive recordings
Electrical stimulation of brain
Video EEG
Goal to record all possible seizure type ,atleast
onset of all as described by patients.
D/D between seizure vs paroxysmal event.
Define symptomatic zone and ictal onset zone.
Taper of AED may be required.
MRI Brain
Define lseional zone.
Tumours – Glioma, DNET
Mesial temporal sclerosis
Vascular malformation –cavernous hemangioma
 Cortical Dysplasia

Functional MRI – Define eloquent area of brain.

Spect/PET
Interictal – define area of hypometabolism

Ictal Spect – define ictal onset zone.useful in MRI

negative cases.
Pscyhometry
Left temporal – verbal memory
Right temporal – visual memory.
Used to correlate with lateralisation and
localise.
Document deficit .
 Criteria for surgery
1. Focal seizure onset should be established.

2. Progressive neurological diseases, such as malignant brain tumor

or multiple sclerosis, should be excluded.

3. Resistance to medical treatment may become evident already after

several months.

4. Seizures should be interfering with daily life activities,

social adaptation and be incapacitating for patient.

Mental retardation, low IQ scores or psychiatric diseases are no

longer considered as contraindications for epilepsy surgery
 Phases of presurgical evaluation of epilepsy
Phase I – noninvasive methods · (sufficient in up to 90% of patients)
Video monitoring and surface EEG (and sphenoidal recording if
possible) >30 channels.
· MRI and fMRI
· PET and SPECT
· Neuropsychological evaluation
· Wada test

Phase II – invasive methods · Intracranial EEG recording by using:

– subdural electrodes
– depth electrodes
– foramen ovale electrodes
Steps
Initial screening refractory seizures for possible
surgery.
Detailed evalaution – history taking and
examination.
Video telemetry to capture seizures.
 MRI / f MRI
Psychometry/Psychiatric evlaution.
Team meeting and decision for surgery.
Meisal Temporal Sclerosis
Age of onset – childhood to young adult.
H/O Febrile seizures.
Abdominal/psychic aura –Typical automotor
seizures with secondary generalisation.
MRI brain – epilepsy protocol
Sleep EEG – anterior temporal spikes ( F7, F8m
T1,T2)
Surgery
Anterior temporal lobectomy – total removal of
amygadala/hippocampus with resection of
anterior temporal lobe – 5cm on rt side n 3cm on
left side.
Complications
-Memory/language deficit.
-Superior quadrantopia
-Cranial nevre palsy – 6th, 3rd, 4rth
-Hemiparesis