Surgery of Cerebrovascular Lesions Causing Intractable Epilepsy

ABSTRACT

OBJECTIVE: Traditionally, the main indications for surgery in vascular-related lesion were based upon reduction or control of seizures, reversal of symptoms of deficits related to mass effect, and prevention of hemorrhage or recurrent hemorrhage. However, the results of surgical treatment for seizure control are disappointing in some reports. Here we describe surgical strategies and our experience in treating patients with intractable seizures associated with vascular-related lesions according to sophisticated presurgical and intraoperative evaluation. METHODS: Twelve(4.5%) patients were selected for this study out of total 264 patients with resective epilepsy surgery at our epilepsy center during four years since 1992. All were treated with anticonvulsant agents but became refractory. These patients operated on under local or general anesthesia for resection surgery, underwent presurgical and intraoperative evaluation for identification of adjacent, beyond or remote epileptogenic area and the eloquent area. RESULTS: Of these 12 patients, vascular malformations(AVM, cavernous angioma) were 7, overt hemorrhage due to vascular lesion were 2 and intractable ongoing seizure after vascular surgery were 3. Other vascular lesion including occlusive disease, moyamoya disease or previous hemorrhage were excluded in this study. The location of the lesion was mainly temporal and peri-Rolandic areas, and dual pathology was verified in 2 cases of 6 temporal lesion. The surgical outcome(class I;7, II;3, III;1, IV;1) was excellent by Engel's classification. CONCLUSION: Control of seizures related to vascular lesions remains strong indication for surgical resection. For this reason, careful presurgical evaluations are essential to evaluate the remote epileptogenic area, especially in temporal lesion. Intraoperative acute recording(ECoG) and functional mapping by electrical stimulation or SSEP are important for maximal resection of epileptogenic area with minimal sequellae.