Neurosurgery

Frontal-lobe resections are the most common extratemporal removals and a variety of pathological conditions are found with the overall complete seizure relief rate, reported in the literature to be around 20%. The Montreal Neurological Institute has the largest series of frontal-lobe resections and, in their last review of 257 patients with non-tumoral lesions, 26% had complete freedom from seizures and a further 30% had a marked reduction in seizures. Forty-seven percent of patients undergoing anterior frontal resections become seizure free compared with only 18% of those with parasagittal resections. This review is clearly well before the advent of direct brain imaging and it is now clear that the presence of a lesion on MRI alters the outcome favorably.

Resection from the central (parietal) region is rare. When there is a pre-existing deficit, then there is less likelihood of an increase as a result of operation and, therefore, it is more reasonable to attempt it. Surgical technique is important, especially care for the deep vessels, which may indeed have to be skeletonized to avoid deficits distant from the site of the resection. Modern methods of brain imaging, such as functional PET or functional MRI combined with surface rendering, including venous structures, can provide the surgeon with a precise map of the brain surface and pathology. The results of resections from the central and parietal areas are variable.

Occipital resections are also rare. There is a difficulty because seizure spread from the occipital lobe invariably involves the temporal lobe, often bilaterally, and temporal lobe seizures themselves can have visual components in their semiology. Modern brain imaging has made a considerable difference to the outcome of surgery in this area. It is now realized that most patients harbor either a low-grade tumor or a developmental abnormality. In 1998, Spencer reported 35 patients with either tumors or developmental abnormalities, reporting 85% good outcome in the tumors and 46% in the

Table 34.5. Outcome in large series of temporal lobe resections.

Outcome group

Operation

Palm Desert II (%)

ILAE Global Survey (%)

I (Seizure free)

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