Epilepsy surgery: removing the thorn from the lion's paw.

In the United States, 10,000 to 20,000 patients have epilepsy uncontrolled by medication. The addition of a second-line drug to the primary regimen has a 2% to 11% chance of controlling the seizures. We present a series of 35 patients with intractable epilepsy who had surgical resection of their seizure focus. Seventy-five percent of the patients with temporal lobe epilepsy were made seizure free, with an additional 14% sustaining a greater than 90% reduction in seizures (decrease in number and frequency). Seventy-one percent of the patients with extratemporal lobe epilepsy (seizures originating outside the temporal lobe) had a worthwhile reduction (> 90%) in their seizures. Two patients sustained permanent clinically significant deficits as a result of their presurgical evaluation or resection. There were no deaths. Epilepsy surgery offers a cure for the "incurable" patient with a morbidity of 5% to 6%.

Natural history of recurrent seizures after resective surgery for epilepsy.

Seizures persist or recur in 20-60% of patients after resective surgery for intractable partial epilepsy. Further information about the natural course of these seizures is lacking in the literature. During one decade of epilepsy surgery at a single institution, we identified 72 patients with recurrent postoperative seizures after resective procedures for epilepsy. Prospectively compiled seizure diaries, hospital records, and outpatient office records were reviewed and supplemented by telephone communications to assess subsequent seizure frequency. Follow-up data was available ranging from 6 months to 7 years 5 months (mean 3 years 5 months). The likelihood of persistent seizures and recurrent intractability was examined with life-tables. Seizures recurred within the first postoperative year in 86% of patients and were similar to preoperative events in 74% of patients. After the first seizure recurrence, there was 80% likelihood of persistent seizures in the next 6 years and 40% likelihood of intractability (more than one seizure a month despite optimal medical therapy). The interval until recurrence within the first postoperative year did not affect the likelihood of subsequent seizures or intractability. Late seizure recurrence (after the first year) was not associated with any instances of subsequent intractability. Recurrent seizures after extratemporal resections were more likely to become persistent and intractable than seizures recurring after temporal resections. This information provides rational prognostication and assists in counseling patients with recurrent seizures after resective surgery for intractable epilepsy.

Noninvasive evaluation of ischemic stroke with SPECT.

Technetium Tc 99m DTPA single photon emission computerized tomography (SPECT) brain scans of 20 patients with acute ischemic stroke were reviewed retrospectively and compared with clinical and radiologic (CT) data. Fourteen of the patients had abnormal SPECT studies. The abnormal findings were demonstrated by static views in eight patients, by the flow study in one patient, and by both sets of images in the other five patients. All abnormalities correlated with the clinical syndrome of presentation, and only two of the patients had no corresponding lesions on CT. Of the six patients with normal SPECT scans, two had abnormal CT studies, and in the other four, no lesions were shown at all. The ability of 99mTc DTPA SPECT to display cerebral infarctions appears to be, at best, comparable to that of CT. SPECT also provides qualitative information regarding flow dynamics in the affected hemisphere of some patients (6/20 in our review). This, we believe, represents the objective demonstration of the preexisting insufficient collateral flow in the hemisphere at risk for ischemic stroke.