Editorial: Seizure surgery

Abstract

For years, surgeons and neurologists have debated the value of standard temporal lobe resections (mostly performed before 1996) compared with selective amygdalohippocampectomy (performed after 1995) in the management of temporal lobe epilepsy. This debate has raged due to comparisons on seizure outcome; morbidity; language; and cognitive, visual, and behavioral results. In this report, the authors compare a well-matched, noncontemporaneous cohort of patients with mesial temporal sclerosis who underwent surgery.1 The average length of follow-up after standard temporal lobectomy was almost 10 years and for selective surgery, almost 7 years. When a favorable outcome was defined as Engel Class I or II, there was no difference in epilepsy control. In addition, the authors found no difference in cognitive or psychological outcomes for the two resection strategies. Selective surgery was associated with more seizures while patients were reducing medication; the authors raised the issue that this could affect quality of life. They also theorized that selective surgery might be a better choice in patients with more severe preexisting psychiatric illness. Whether or not the findings of increased paranoia after temporal lobectomy would be validated in a larger patient series remains to be seen. One limitation of the study is that psychiatric outcomes were only available in a subset of the population, which was related to differences in the treating neuropsychologist. Clearly this represents a limitation of retrospective reviews for which a specific protocol for patient evaluation was not in place. Indeed, in a noncontemporaneous study one can always question the importance of experience gained over time, both in terms of patient selection and surgical technique. There have been numerous articles that compared the value of standard temporal lobectomy to more selective resections. It seems that in skilled hands, one approach may not have clear advantages over the other but one may be more appropriate for individual patients. Important questions beyond the scope of this research remain. Why do not more patients undergo epilepsy surgery, given its proven value in properly selected candidates? Will new imaging techniques such as high-definition fiber tracking show that preserved or resected limbic pathways make a difference in outcome? Will selective surgery be redefined further based on that knowledge? (http://thejns.org/doi/abs/10.3171/2013.1.JNS121886) Disclosure