Surgical approaches in nonlesional neocortical epilepsy

Abstract

There is inherent difficulty in identifying the epileptogenic zone in nonlesional neocortical epilepsy, which leads to the incomplete resection. However, with careful interpretation of other studies including functional neuroimaging and concordant results, surgical treatment can benefi t patients with nonlesional neocortical epilepsy. Two recent large studies including ours demonstrated that seizure free outcomes were 47 and 55% for nonlesional TLE, and 41 and 43% for nonlesional extratemporal lobe epilepsy patients. Concordance with two or more presurgical evaluations among interictal EEG, ictal EEG, FDG-PET, and ictal SPECT was signifi cantly related to a seizure-free outcome. However, we should always the possibility of false localization of ictal EEG or functional neuroimaging in nonlesional neocortical epilepsy. Careful placement of intracranial electrodes on adjacent areas should be needed for these patients. The repositioning of intracranial electrodes might identify a new ictal onset zone. Consideration of one-week interval repositioning of intracranial electrodes could be helpful in selected patients. Intracranial EEG is one of the most important procedures in planning surgery and achieving a good surgical outcome in resective epilepsy surgery. Slow propagation and focal or regional ictal onset were associated with a seizure-free outcome. Resection that includes more electrodes with ictal rhythm or interictal abnormalities predicts a good surgical outcome.