Cirugía de la Epilepsia.- Tratamiento Quirúrgico


En esta sección se ponen a disposición de todos los usuarios y pacientes, una lista de publicaciones relacionadas con la Cirugía de la Epilepsia en los que han participado activamente miembros del equipo médico de la Unidad de Neurocirugía.

Esta sección dada su importancia se subdivide en otras cuatros subsecciones:

Tratamiento Quirúrgico

Estudios Clínicos Neurofisiológicos

Estudios Neuroradiológicos

Estudios Neuropsicológicos

Estudios Anatomopatológicos

Estudios Preoperatorios

Estimulación cerebral profunda talámica para la epilepsia resistente

Cristina V. Torres, Jesús Pastor, Eduardo G. Navarrete, Rafael G. Sola.

Resumen: . La epilepsia es un trastorno neurológico que afecta al 1-2% de la población. A pesar de los tratamientos dispo- nibles (farmacoterapia, cirugía resectiva, estimulación del nervio vago…), hay un subgrupo importante de pacientes que continúa teniendo crisis incapacitantes. La estimulación cerebral profunda está experimentando un incremento exponen- cial de sus indicaciones y se dispone de experiencia amplia en el campo de los movimientos anormales. El tratamiento de la epilepsia mediante estimulación cerebral profunda podría ser una nueva terapia aplicable al subgrupo de pacientes resistentes a otros tratamientos. Los experimentos con modelos animales, y el avance en los conocimientos neurofisiológicos de los procesos que gobiernan la génesis de la epilepsia, han dado pie a la selección de diversas dianas cerebrales para la estimulación. El tálamo, por ser un centro fundamental de relevo en los circuitos corticotalámicos y corticoestriado-talamocorticales, ha sido objeto de estudio con esta finalidad. Los estudios realizados en pacientes epilépticos han tenido distintos grados de efectividad, si bien los estudios controlados no permiten conclusiones definitivas sobre cuál es su pa- pel en el tratamiento de la epilepsia. Probablemente la selección de pacientes más adecuada favorezca la realización de estudios con conclusiones más determinantes. Es preciso realizar más estudios aleatorizados controlados para extraer conclusiones fidedignas y evidencia científica sobre su eficacia.

Palabras clave: Centromediano. Epilepsia. Estimulación cerebral profunda. Kindling. Neuromodulación. Núcleo anterior.

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Contribución diferencial de los estudios preoperatorios al diagnóstico en la cirugía de la epilepsia temporal

Jesús Pastor, Guillermo J. Ortega, Iván Herrera-Peco, Marta Navas-García, Eduardo G. Navarrete, Concepción Alonso-Cerezo, Paloma Pulido-Rivas, Rafael G. Sola

Resumen:

Introducción. Es preciso conocer el grado de confianza de las pruebas preoperatorias en epilepsia del lóbulo temporal (ELT).
Objetivo. Analizar la importancia relativa de diferentes pruebas preoperatorias –videoelectroencefalograma (vEEG), elec- troencefalograma (EEG), tomografía computarizada por emisión de fotón único (SPECT) y resonancia magnética (RM)–, el grado de concordancia entre ellas y desarrollar un modelo probabilístico bayesiano para el diagnóstico.
Pacientes y métodos. Se ha estudiado a 73 pacientes intervenidos de ELT, con un seguimiento postoperatorio mínimo de dos años. Para analizar la capacidad localizadora, se utilizan únicamente pacientes con un grado I de Engel durante todo el tiempo de seguimiento (n = 60).

Resultados. Los porcentajes de los grados I, II, III y IV de Engel a los dos años fueron del 87,7, 8,2, 3,0 y 0%, respectiva- mente. La concordancia preoperatoria fue < 50% para tres pruebas y del 33% para las cuatro. Se encontraron estudios de RM normales en el 33,3% de los casos. Según el índice de localización, el orden es vEEG > RM > SPECT > EEG. La probabili- dad condicional de obtener un grado I de Engel por prueba es: vEEG (0,950) > EEG (0,719) > SPECT (0,717) > RM (0,683). Para más de dos pruebas, la probabilidad condicional es ≤ 0,587 (vEEG + RM). La probabilidad de obtener un grado I de Engel a priori es vEEG (0,983) > RM (0,414) > EEG (0,285) > SPECT (0,209). El modelo bayesiano resulta ser muy sólido.
Conclusiones. No siempre hay un alto grado de concordancia entre las pruebas, a pesar de lo cual puede obtenerse un buen resultado funcional. La prueba más eficaz es el vEEG.

Palabras clave: Electrodos de foramen oval. Resonancia magnética no lesional. Teorema de Bayes. Videoelectroencefalograma.

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Epilepsia refractaria como presentación de absceso cerebral brucelósico

R. Carrasco-Moro, E. García-Navarrete, M. Pedrosa-Sánchez, J.M. Pascual-Garvi, M. Minervini-Marín, R.G. Sola

Resumen:

Brucellosis is a zoonotic disease that is occasionally transmitted to human beings from infected animal reservoirs. It is an important condition in endemic areas. One infrequent complication of systemic brucellosis is the infection of the central or the peripheral nervous systems. Case report. A 54-year-old male who was being studied prior to surgery for refractory epilepsy, with clinical expression in the form of complex partial seizures. Neuroimaging findings revealed an expansive lesion in the right temporal lobe, which direct serological, histopathological and microbiological evidence showed to be a chronic brucellar abscess. After combined treatment involving complete surgical resection followed by a cycle of standard antimicrobial therapy, the patient was seizure-free at one year of follow-up. Conclusions. Despite its low frequency, infection by Brucella must be considered in the differential diagnosis of intracranial expansive lesions, as well as in the case of patients whose presenting symptoms are epileptic seizures. To perform the diagnosis it is especially important to be aware of the wide range of clinical and radiological manifestations that can be produced, and which do not always correlate. Identification of risk factors on the patient record is also a crucial step. [REV NEUROL 2006; 43: 729-32]

Palabras clave: Abscess. Brain. Brucellosis. Epilepsy. Magnetic resonance imaging. Neurobrucellosis.

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Morbidity associated with the use of foramen ovale electrodes

Jesús Pastor, Rafael G. Sola, Virgilio Hernando-Requejo, Eduardo G. Navarrete, and Paloma Pulido

Resumen:

Purpose: The identification of the epileptic zone in patients with mesial temporal lobe epilepsy sometimes requires intracranial recordings, for example, with foramen ovale electrodes (FOE). This paper reviews and analyzes the resulting com- plications in a series of patients studied with bilat- eral FOE for presurgical evaluation. Methods: The clinical records of 331 consecutive FOE implantations in 329 patients were reviewed. Complications related to FOE were divided into two groups: those that were non–life-threatening or not directly attributable to FOE, or life- threatening complications and those clearly re- lated to FOE. Results: The mean length of hospital stay in the v-EEG unit with FOE was 5.8 ± 0.2 days (range 1–19) following a bimodal distribution (peaks at 4 and 8 days). Complications were observed in 6.64% of patients, but in 4.83% of cases, complica- tions were non–life-threatening (moderate disaesthesia, cheek bleeding, FOE expulsion). Complica- tions were only severe in 1.81% of patients (clot- ting or intracranial hemorrhage). One patient died more than 20 days after FOE removal and after sev- eral episodes of status epilepticus. Patients suffer- ing from life-threatening complications were more likely to be female (83.3%) than patients experienc- ing no complications or non–life-threatening com- plications. Patients with life-threatening complica- tions had a more prolonged stay in the v-EEG unit during monitoring with FOE (8.2 ± 0.7; n = 6) than the group without complications (5.7 ± 0.2; n = 309; p < 0.01; Kruskal–Wallis test).
Discussion: FOE is a reasonably safe intracranial technique for v-EEG monitoring with low rates of potentially severe complications, but its indication should be carefully evaluated, especially if monitor- ing for more than 8 days is expected.

Palabras clave: Facial pain—Intracranial hemorrhage—Intracranial v-EEG—Temporal lobe epilepsy.

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Epilepsia refractaria como presentación de absceso cerebral brucelósico

R. Carrasco-Moro, E. García-Navarrete, M. Pedrosa-Sánchez, J.M. Pascual-Garvi, M. Minervini-Marín, R.G. Sola

Resumen:

Brucellosis is a zoonotic disease that is occasionally transmitted to human beings from infected animal reservoirs. It is an important condition in endemic areas. One infrequent complication of systemic brucellosis is the infection of the central or the peripheral nervous systems. Case report. A 54-year-old male who was being studied prior to surgery for refractory epilepsy, with clinical expression in the form of complex partial seizures. Neuroimaging findings revealed an expansive lesion in the right temporal lobe, which direct serological, histopathological and microbiological evidence showed to be a chronic brucellar abscess. After combined treatment involving complete surgical resection followed by a cycle of standard antimicrobial therapy, the patient was seizure-free at one year of follow-up. Conclusions. Despite its low frequency, infection by Brucella must be considered in the differential diagnosis of intracranial expansive lesions, as well as in the case of patients whose presenting symptoms are epileptic seizures. To perform the diagnosis it is especially important to be aware of the wide range of clinical and radiological manifestations that can be produced, and which do not always correlate. Identification of risk factors on the patient record is also a crucial step. [REV NEUROL 2006; 43: 729-32]

Palabras clave: Abscess. Brain. Brucellosis. Epilepsy. Magnetic resonance imaging. Neurobrucellosis.

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Epilepsia farmacorresistente del lóbulo temporal. Exploración con electrodos del foramen oval y resultados quirúrgicos

R.G. Sola, V. Hernando-Requejo, J. Pastor, E. García-Navarrete, J. De Felipe, M.T. Alijarde, A. Sánchez, L. Domínguez-Gadea, P. Martín-Plasencia, F. Maestú, J. De Felipe-Oroquieta, S. Ramón-Cajal, P. Pulido-Rivas

Resumen:

Aim. To report our experience in the surgical treatment of temporal-lobe epilepsy. Patients and methods. An analysis was performed of the outcomes of 137 patients submitted to surgery between 1990 and 2001, with a follow-up of more than two years. A study was conducted of the percentages of successful detection by the different complementary tests – MRI, EEG, interictal SPECT, video-EEG with foramen ovale electrodes (FOE), neuropsychological study (NPS) – and the precision with which they reported the epileptogenic focus. Results and conclusions. Successful surgical outcomes (Engel grades I-II): 73.4%. No surgical mortality occurred, although some mild, reversible morbidity was observed. Surgical outcomes were not affected by sex, age, age of onset and the length of time the patient had had the disease, or the frequency of the seizures. No association was found between seizures in the immediate post-operative period and a poorer long term control of the epilepsy. MR images were normal in 25% of patients; in these cases the surgical outcomes (Engel grades I-II at two years: 62%) were significantly poorer than in cases of tumours/cavernomas (86%); RMI studies of other types of lesions gave intermediate results (72%). With respect to the capacity of the different tests to lateralise/locate the epileptogenic focus, video-EEG-FOE proved to be the best, followed by MRI, SPECT, EEG and NPS. [REV NEUROL 2005; 41: 4-16]

Palabras clave: Epilepsy surgery. Foramen ovale electrodes. Pharmacoresistance. Temporal lobectomy. Temporal-lobe epilepsy.

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Impacto de la experiencia sobre los resultados quirúrgicos en la epilepsia del lóbulo temporal

J. Pastor, V. Hernando-Requejo, L. Domínguez-Gadea, I. de Llano, M.L. Meilán-Paz, J.L. Martínez-Chacón, R.G. Sola

Resumen:

Recently, we have published the results of a first surgical series of patients with temporal lobe epilepsy (TLE). We describe a posterior series of patients intervened of TLE, we compare the functional results with the previous series and we finally analyze the causes of changes. Patients and methods. We studied the first 22 consecutive patients surgically intervened of TLE with a minimum post-surgery follow-up of 2 years. Patients showing I and II Engel’s grade were used as gold standard for evaluation of pre-surgical complementary studies. Results. We have obtained better functional results: 91% patients showing Engel’s grade I, 9% showing grade II and neither III nor IV grades were obtained. Pre-surgical studies changed in comparison with the previous report. The most improving change was observed in video-EEG with foramen-ovale electrodes (FOE) (37%), scalp EEG (26.6%), interictal SPECT (11.7%) and MRI (11.7%). Video-EEG with FOE was the study than showed greater concordance with epileptic focus (95.5%), followed by EEG (86.4%). In 35% of cases, MRI was normal or without valid data for correct localization of focus. Conclusions. Video-EEG with FOE and TLE surgery are safety methods, which results improve with the experience. Normal or not informative MRI do not should a priori reject those patients with drug-resistant TLE from surgery. [REV NEUROL 2005; 41: 709-16]

Palabras clave: EEG. Foramen ovale electrodes. Interictal SPECT. Temporal lobe epilepsy. Temporal lobectomy. Video-EEG.

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Epilepsia farmacorresistente del lóbulo temporal. Aportaciones de la neurofisiología clínica

Tesis doctoral Dr. Ignacio de LLano San Claudio

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Ínsula de Reil y epilepsia farmacorresistente

M. Pedrosa-Sánchez, M. Escosa-Bagé, E. García-Navarrete, R.G. Sola

Resumen:

Over the last few years surgery has been developing, with promising results, methods to treat an important number of cases of partial epilepsy that are related, to different extents, with the lobe of the insula and display pharmacoresistance. Better knowledge of the anatomofunctional particularities of this region of the cortex, new neuroimaging and neurophysiological techniques, together with the use of the surgical microscope, stereotactic support and neuronavigation, have had a strong influence on the development of this type of surgery. Case report. In this paper we report three cases of patients with epilepsy and who were diagnosed as suffering from structural lesions of the insular region: two cavernomas and an oligodendroglioma. The preoperative study was carried out using magnetic resonance imaging, angiography and video-EEG. The surgical procedure consisted in a transsylvian approach with electrocorticography, which provided us with the clinical results we have studied. Conclusions. The correct approach to the diagnosis of the epileptogenic insular lesions must include a complete neurophysiological study and preoperative planning with angiography. This allows their surgical resection through the transsylvian approach and enables us to obtain, with a very low degree of morbidity, clearly satisfactory results as regards the decrease in the number of seizures in these patients. [REV NEUROL 2003; 36: 40-4]

Palabras clave: Brain glioma. Cavernous angioma. Drug-resistant epilepsy. Insular lobe. Transsylvian approach.

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