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| EDITORIAL |
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| Year : 2013 | Volume
: 61
| Issue : 3 | Page : 215-216 |
Cerebral cavernomas and intractable epilepsy: What should be the extent of resection for optimal seizure outcome?
J. M. K. Murthy
Department of Neurology, Continental Institute of Neurosciences and Rehabilitation, Continental Hospitals, IT and Financial District, Gachibowli, Hyderabad, India
| Date of Submission | 26-Jun-2013 |
| Date of Decision | 26-Jun-2013 |
| Date of Acceptance | 26-Jun-2013 |
| Date of Web Publication | 16-Jul-2013 |
Correspondence Address:
J. M. K. Murthy
Chief of Neurology, Continental Institute of Neurosciences and Rehabilitation, Continental Hospitals, IT and Financial District, Gachibowli, Hyderabad - 500 035
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.115049
How to cite this article:
Murthy J. Cerebral cavernomas and intractable epilepsy: What should be the extent of resection for optimal seizure outcome?. Neurol India 2013;61:215-6 |
Cavernoma is one of the common causes of lesional epilepsy and these lesions are estimated to occur in about 0.5-07% of the population [1] and account for 10-20% of all intracranial vascular malformations. [2] With the advent of magnetic resonance imaging, they are being increasingly recognized. Cavernomas are dynamic lesions that are prone to seizures over time. [2] Seizures are the most common presenting symptoms in about 80% of patients [3] and about 40% of these patients develop intractable epilepsy. [3],[4],[5],[6]
Cavernomas located in the cerebral cortex, immediate subcortical regions, or adjacent to the amygdale or hippocampus are more likely to be epileptogenic. [7] Of the supratentorial cavernomas, 63% have been lobar in location, 22% frontal, and 20% temporal. [3] The exact basis of epileptogenesis in patients with cavernoma is not understood. Cavernoma is not itself epileptogenic, but the cerebral cortex immediately adjacent to the lesion including the hemosiderin ring is the focus. Most evidence suggests that the breakdown products caused by repeated small microhemorrhages deposit ferric ions into the surrounding cortex which are highly epileptogenic. Evidence from the experimental studies suggests that iron injected into the cortex can result in focal seizures. [8],[9] This concept has clinical implications while determining the extent of resection in patients with intractable epilepsy to optimize postoperative seizure control.
The optimal management of patients with cavernoma and intractable epilepsy is still a matter of debate. Considering the natural history of cavernomas, the favorable neurologic and seizure outcome, surgical resection shall be the option in these patients. [10] Resective surgery offers an excellent chance for seizure control. Long-term seizure control (Engel class I) is high after surgical resection and the reported rates range between 70% and 85%. [3],[6],[10] Factors associated with good seizure outcome included age older than 39 years at the time of surgery, mesio-temporal location, size less than 1.5 cm, and the absence of secondarily generalized seizures. [10]
The reported Engle class I outcome after lesionectomy has been 70% at 1 year and 65% after 3 years. [10] Improved seizure outcomes have been reported with the resection of hemosiderin ring along with cavernoma compared to lesionectomy. [4],[10],[11],[12],[13] In the series reported by Baumann et al., [12] additional removal of hemosiderin ring resulted in better seizure outcome (Engle class I) to 77% compared with 65% for lesionectomy alone. In the series of Wang et al., [14] reported in this issue of the journal, Engel class I outcome with the removal of hemosiderin ring at 1 year follow-up was 74.4% compared with 59.5% with lesionectomy alone and the corresponding figures at 5-year follow-up were 59.5% and 27.8%, respectively. In select patients with the most severe intractable epilepsy, Chang et al. [6] reported 86% Engle class I seizure outcome when resection was guided by electrocorticography (ECoG). In the series of Van Gompel et al., [7] the use of ECoG in patients with temporal lobe cavernomas and intractable epilepsy has resulted in Engel class I outcomes as follows: 77% versus 90% at 1 year, 79% versus 83% at 2 years without ECoG versus with ECoG, respectively. In this study, among the patients with temporal lobe cavernomas, those who underwent ECoG typically had a more extensive parenchymal resection rather than a lesionectomy.
In patients with cavernomas and intractable epilepsy, probably the epileptogenic zone includes the cavernoma and the cerebral cortex immediately adjacent to the lesion including the hemosiderin ring. The data analyzed suggest that in patients with cavernoma and intractable epilepsy, seizure outcome is better with lesionectomy plus removal of hemosiderin ring than with lesionectomy alone. Superior seizure-free outcomes can be achieved if the resection is guided by intraoperative ECoG. Thus, there is a need for a paradigm shift from lesionectomy alone to more extensive ECoG-guided resection to optimize postoperative seizure control.
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