engleski

New possibilities in the neurosurgical treatment of patients with pharmacoresistant epilepsy (corpus callosotomy, gamma-knife surgery, disconnection procedures)

Neurosurgical techniques of treating patients with pharmacoresistant epilepsy have changed considerably in the last 30 years. This improvement is mostly due to large progression in imaging technology, but also in neurophysiologic methods and microsurgical techniques. Greatest success has been achieved in patients with magnetic resonance imaging (MRI) positive temporal lobe epilepsy, especially in patients with hippocampal sclerosis, and more recently in patients with extratemporal lesional epilepsy. Very important is careful presurgical evaluation, which should define clear semiology of seizures, epileptogenic lesion(s) or zone, symptomatogenic zone, irritative zone, ictal zone and zone of potential functional neurological deficit because of anatomical connections with eloquent region. Phase I and II of the presurgical evaluation are routinely being performed at Zagreb University Hospital Center. In the near future, we also plan to perform corpus callosotomy, which has been shown very eff ective in reducing drop attacks (tonic or atonic), as well as attacks connected with complex forms of polymicrogyria, tuberous sclerosis and malignant forms of primary generalized epilepsies with encephalopathies. However, we want to point out the well-known adverse effect of callosotomy, i.e. ‘disconnection syndrome’. By avoiding complete disconnection, we can reduce the prevalence of the mentioned syndrome. Also, focus of our interest in clinical neurology are hamartomas, especially hypothalamic hamartomas (HHs), rare congenital heterotopic lesions composed of neurons, glia, and myelinated fi bers, characterized by several peculiar symptoms, including precocious puberty, gelastic and dacrystic seizures. Based on MRI finding, they can be divided into four main types. Types I and II are defined as HHs attached to the floor of the third ventricle with narrow (type I) or broad (type II) interfaces, type III (‘straddling’) is defined as HH extending into the third ventricle and interpeduncular cistern, and type IV as HH located totally within the third ventricle. The treatment of HHs has evolved considerably over the past two decades. Gamma-knife surgery (GKS) is clearly the safer and eff ective approach for type I, type II and small type III HHs, while in large type III and IV HHs, GKS achieves disconnection that leads to seizure reduction. We present several interesting patients operated on in the last year at our institution for encephalocele located in the tip of the temporal lobe. We will also present one patient with Dravet syndrome, who was a candidate for corpus callosotomy, and two patients treated with GKS for HHs.

epilepsy surgery; pharmacoresistancy; corpus callosotomy; gamma-knife surgery; disconnection procedures

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