Tuesday, January 16, 2018

The start and development of epilepsy surgery in Europe


Olaf E. M. G. Schijns1,3 & Govert Hoogland1,2,3 & Pieter L. Kubben1,3 & Peter J. Koehler4

Abstract Epilepsy has not always been considered a brain disease, but was believed to be a demonic
possession in the past. Therefore,trepanationwasdonenotonlyformedicalbut also for religious or
spiritual reasons, originating in the Neolithic period (3000 BC). The earliest documentation of
trepanation for epilepsy is found in the writings of the Hippocratic Corpus and consisted mainly of
just skull surgery. The transition from skull surgery to brain surgery took place in the middle of
the nineteenth century when the insight of epilepsy asacorticaldisorderofthebrainemerged.
Thisledtothestart of modern epilepsy surgery. The pioneer countries in which epilepsy surgery
was performed in Europe were the UK, Germany, and The Netherlands.
Neurosurgical forerunners like Sir Victor Horsley, William Macewen, Fedor Krause, and Otfrid Foerster
started with Bmodern^ epilepsy surgery. Initially, epilepsy surgery was mainly done with the purpose
to resecttraumaticlesionsorlargesurfacetumours.
Inthecourse of the twentieth century, this changed to highly specialized microscopic
navigation-guided surgery to resect lesional and non-lesionalepileptogeniccortex.The development
of epilepsy surgery in Southern Europe, which has not been described until now, will be elaborated
in this manuscript.
To summarize,inthispaper,weprovide
(1)adetaileddescription of the evolution of European epilepsy surgery with special emphasis
    on the pioneer countries;
(2) novel, never published information about the development of epilepsy surgery in Southern Europe; and
(3) we review the historical dichotomy ofinvasiveelectrode implantationstrategy(Anglo-Saxonsurface
    electrodes versus French-Italian stereoencephalography (SEEG) model).



...The development of epilepsy surgery in Greece

The modern era of epilepsy surgery in Greece started in 1997 in the Evangelismos General Hospital, the largest
hospital in Greece.In2000,followingthejointdecisionoftheUniversity of Athens and Evangelismos General Hospital,
the Athens University Department of Neurosurgery was located in Evangelismos Hospital. In the following years,
a multidisciplinary epilepsy team was organized consisting of neurosurgeons, neurologists, neurophysiologists,
neuroradiologists, neuropsychologists, psychiatrists, and epilepsy nurses.

Specialized investigations were introduced such as the Wada test, the intraoperativeelectrocorticography(ECoG),
and the intracranial video-EEG monitoring besides the standard presurgical investigations like video EEG, MRI,
functional MRI, PET, SPECT, neuronavigation, and neuropsychological and psychiatric assessments,
In 2001, the first standard temporal lobectomies and the first extra-temporal cortical resections were
performed [63]. In2002,thefirstanteriormedialtemporallobectomiesandthe first selective amygdalohippocampectomies
were performed [62]. In 2003, the Epilepsy Surgery Unit was substantially upgraded.

The upgraded unit included a fully equipped video-EEG suite, a completely renovated operation theatre, advanced
targeting and neuronavigation systems, and upgraded neuroimaging techniques such as functional MRI,
MRI spectroscopy, and PET. In 2004, the Athens Epilepsy Surgery Centre was officially inaugurated.

Since then, examination of intractable epilepsy cases has become a routine practice. Particularly, in extra-temporal
epilepsy cases, immediately after the positioning of intracranial electrodes, the patient undergoes video-EEG
monitoring and cortical mapping.

A week later, the patient is usually ready for ECoG-guided cortical resections. Multiple subpial transsections are
performed in patients, in whom the epileptogenic area is located in eloquent cortical areas [27].

In 2009, the first cortical stimulation procedure was done in a patient with an eloquent cortical epileptogenic
zone, and in 2010, the Athens Epilepsy Surgery Centre started performing procedures of deep brain stimulation.
Deep brain stimulation (DBS) brain targets included the hippocampus and the anterior thalamic nucleus.
The number of epilepsy operations performed between 1997 and 2011 exceeds 200. The strict referral base
is a population of approximately 7 million from the area of Athens, South Greece, and the Greek islands,
but the actual referral base is much wider including patients from northern Greece andneighboring countries
such as Albania, Bulgaria, and Cyprus and also people of Greek descent living in other European countries
(personal communication with Prof. S. Gatzonis, 2012). In St. Luke’s Hospital, a private hospital located in the
suburbs of the city of Thessaloniki, in Northern Greece, the Epilepsy Monitoring Unit was established in 2002,
initially devoted to diagnostic video-EEG studies with occasionally only non-invasive presurgical evaluations and
operations in well-selected lesional, mostly temporal lobe epilepsy, cases. Since 2006 and 2007, the proportion
of presurgical evaluations has increased considerably and investigational facilities have been enriched by the addition
(in 2009) of fMRI and EEG-fMRI and intracranial electrode monitoring.

Actually, it is a two-bed video-EEG epilepsy monitoring unit performing
prolonged video-EEG studies for diagnostic and presurgical evaluation purposes in adults and school-age children.
The referral population (city of Thessaloniki and Northern Greece) approaches 2.5 million people.
There are also referrals from other areas of Greece and nearby countries (e.g., Albania and Cyprus).
In the period 2009–2011, there were 20–25 admissions for presurgical evaluation/year with 10–12 resections/year
and 2–4 patients/year who have been implanted with intracranial electrodes.
Chronic intracranial electrode monitoring and extra-operative electrical cortical stimulation studies are performed
since 2009.

Untilnow, only investigations with combinations of subdural grids and strips have been performed.
Future plans include SEEG/depth electrodestudiesforselectedcases.Almost80%oftheoperations were performed
for temporal lobe epilepsy by anterior (Spencertype) t e m p o r a l l o b e r e s e c t i o n p l u s
amygdalohippocampectomy.Theother20%oftheoperations were extra-temporal epilepsy cases with focal cortical
resections and occasionally multilobar resections. Acute intraoperative ECoG is utilized in most temporal and
extra-temporal cases for confirmation of epileptogenicity and modifications of resections in selected cases
[26, 59, 60].
Follow-up information is available on a yearly basis for at least 90 % of the operated patients with 80 % of the
patients having an Engel class I outcome, 15 % a class II–III, and 5 % a class IV outcome....


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