Contemporary surgical management of drug-resistant focal epilepsy

ABSTRACT

Introduction: Seizures, which could not be controlled by drug therapy, have profound negative influence on the quality of life of the affected person. If with clear locus of origin and accompanied by loss of consciousness, drug-resistant epilepsy could be treated by surgery.

Areas covered: The aim of this article was to review current status of epilepsy surgery through description of the most important operative methods and narrative comparison of their benefits and harms. In total 1154 articles were retrieved from MEDLINE, SCOPUS, EBSCO, and SCINDEKS databases, and 78 included in the review. The review included systematic reviews, meta-analyses, clinical trials, observational studies on humans, case series, and case reports.

Expert opinion: Sophisticated diagnostic methods nowadays offer much more precise localization of epileptogenic focus and detailed planning of a surgical procedure which will make minimal damage of neural pathways and structures essential for movements, speech, cognition, and emotions. Advent of perioperative care, and improved diagnostics and surgical techniques resulted with significant drop in rates of postoperative complications, long-term neurological deficit, and mortality in the last decade, while seizure freedom rate and quality of life increased.

KEYWORDS:

• Drug-resistant epilepsy
• epilepsy surgery
• focal epilepsy
• minimally invasive neuroablative procedures

Article highlights

• Drug-resistant epilepsy is characterized by persisting seizures despite administration of two adequately chosen antiepileptic drugs.

• The patients with clear locus of origin of seizures, which are drug-resistant are candidates for surgical management by either resective or functional neuromodulation procedures.

• It is essential for planning epilepsy surgery to determine preoperatively precise location of the epileptogenic zone and to evaluate risk of postoperative neurological deficit.

• Outcomes of contemporary epilepsy surgery are mostly beneficial: in majority of patients seizure freedom is achieved and quality of life improved, while perioperative mortality and morbidity are minimal.

• Minimally invasive neuroablative surgery showed promising results and could be a step forward in epilepsy surgery, but further studies are necessary to obtain better estimate of benefits and harms.

• Increased utilization of epilepsy surgery in treatment of focal drug-resistant epilepsy is to be expected in the future, with further refinement of techniques and improvement of outcomes.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or conflict with the subject matter or materials discussed in this manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded in part by grant No. 175007 from Ministry of Education, Science and Technological Development of Republic of Serbia.