Introduction

The surgical treatment of epilepsy has developed from empirical observations and theoretical proposals. Surgical interventions fall into two groups: resective surgery, in which an area of brain is removed, generally because it contains a structural abnormality; or functional surgery, in which brain function is modified so as to improve the control of epilepsy.

Between the first attempts at epilepsy surgery in the late 1800s and the modern era over 150 years later, the surgical treatment of epilepsy has been determined by the available methods of investigation and surgical techniques, against the background of current neuroscience knowledge.

The concept of the pathology underlying focal epilepsy emerged in the 1950s and 1960s. The detailed work by Murray Falconer and neu-ropathological colleagues revealed the pathological substrates underlying temporal lobe epilepsy. These substrates are an excellent predictor of outcome.

In the mid-1970s, direct brain imaging by CT and MRI scanning permitted direct visualization of brain pathology. Early CT scans could only be relied upon to demonstrate gross brain pathology and so a concept of lesional epilepsy and lesional surgery appeared. Even now, the published literature distinguishes between lesional epilepsy from hamartomas and DNET tumors and non-lesional epilepsy, even when there may be clear pathology, such as mesial temporal sclerosis (MTS). Because MTS is predominantly, but not exclusively, unilateral, its demonstration with direct brain imaging is more complex than other pathologies, with the exception of cortical neuronal migration disorders. However, continued advances in MRI imaging have allowed the better delineation of both these conditions. At present, resective surgery is based upon a multi-disciplinary approach, with a heavy emphasis on underlying pathology and direct brain imaging. Stereotactic methodology, both with frame-based and "frameless" stereotaxy, has gained a place in lesion-directed surgery.

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