Folia Psychiatrica et Neurologica Japonica, Vol. 33, No. 3, 1979
Discussion from the Neurosurgical Point of View Kazuo Takeuchi, M.D. Department of Neurosurgery, Kyorin University School of Medicine, Tokyo
In Japan, not a few epileptic patients have been and are being treated at neurosurgical clinics. Many have been nonsurgical epileptics in addition to patients with symptomatic epilepsy due to various organic lesions. The main reasons for this situation are as follow:
1. Many epileptic patients do not wish to go to psychiatric clinics, and the number and distribution of neurological or seizure clinics is still insufficient. 2. Many patients believe epileptic seizures are of traumatic origin, even in cases of minor head injuries. 3. Many patients desire surgery instead of annoying and time-consuming medical treatment. In fact, not a few patients believe surgery can radically treat most cases of idiopathic epilepsy. However, Japanese neurosurgeons routinely prescribe antiepileptics for most patients, as do doctors in other fields. Also, from the neurosurgeons’ point of view, the necessity for surgery in epileptic cases is more apt to be detected in neurosurgical clinics than in clinics of other fields. Naturally, some selected cases of so-called intractable epilepsy, where conventional application of antiepileptics has been of little value, have been treated surgically by certain neurosurgeons. The recent introduction of computerized tomography (CT) is worth mentioning in Received for publication June 25, 1979.
regard to surgical treatment of epilepsy from the neurosurgical point of view. At outpatient clinics, adjuvant examinations of epileptic seizure cases to screen surgical cases include plain craniography and electroencephalography, with radionuclide brain scintiscanning sometimes added if necessary. These are non-invasive methods and more convenient in regard to infant and aged patients. However, such primary screenings are unable to detect all cases requiring surgery as there may be some false negative findings. Secondary adjuvant examinations, namely cerebral angiography, air study, etc., which are more invasive methods of examination, were the only methods available prior to the introduction of CT. Computerized tomography also is non-invasive and essential in primary screening. However, under existing circumstances it cannot be applied to all epileptic outpatients, and only selected cases are subjected to m. The frequency of abnormal CT findings among epileptic patients as reported by neurosurgical clinics in Japan are shown in Table 1. It is rather high, ranging from 8 to 52%. The wide range of frequency may depend on the variety of patients at each clinic. Such abnormal CT findings were found not only at the disease’s onset but also in later stages during follow-up. The frequency of abnormal CT findings in cases of focal seizure is about twice that in cases of general seizure. During the past 18 months, CT examinations have been carried out in 176 cases where the patient’s complaint on his first
K. Takeuchi
414
visit to the outpatient section of the author's clinic has chiefly been at least an epileptic seizure. The frequency of abnormal CT findings has in general reached 52%, as shown in Table 2. Among these cases were 22 (24%) cases of brain tumor and three cases of arteriovenous malformation, as well as other surgical cas& such 'as congenital arachnoid cyst. In other words, about 30% of the cases demonstrating abnormal CT findings require neurosurgical treatment. Such cases were more frequent among patients over 20 years of age, reconfirming the fact that epilepsy among elder age groups should be examined from a neurosurgical point of view. In addition, it is possible that such abnormalities as detected
Table 1:
by CT and which cannot be treated with existing neurosurgical techniques may receive surgical attention in the not too distant future. An illustrated case of neurosurgical epilepsy will be described. A 69-year-old male
CT Findings in Epileptic Patients -..-
Frequency of Abnormal CT (%) 8.7
40
Repcrted by Noya et. a1 Nakajima e t . al. Mori e t . al. Kobityashi et. d.
(73/842)
(32/ 80)
44.7 (17/ 38) 25 (42/160) 16 (13/ 80) General
seiz. 36 (29/ 80) Focal seiz. 52 (91/176) Takeuchi et. 01 45 (67/148) General
seiz. 86
Fig. 1 : Computerized tomography (with contrast enhancement)
(24/ 28) Focal seiz.
Table 2:
CT Findings in Epileptic Patients (June '77-Oct. '78) CT Positive
Seizure Focal seizure < 19 years > 20 years General seizure < 19 years > 20 years Total
Brain Tumor
Miscellaneous 0
5
I ' 4
3
17 2 15 22
19
0 0
Total
24
28
11 8 47
0 3
3
CT Total Negative
91
4 0
81
67 25 22
66
4 12 12
148
27
40
40
41 85
16 12 67 81 176
Prom Neurosurgical Point of View
Fig. 2:
415
Radionuclide brain scintigraphy, right lateral and posterior.
was first seen at our outpatient clinic due to the recent occurrence of generalized convulsive seizure. General neurological examinations, plain craniograms, and electroencephalograms revealed no peculiarities, but contrast-enhanced CT and radionuclide brain scintigrams uncovered a massive lesion in his right occipital region (Figs. 1 and 2). He was hospitalized, and a carefully performed right retrograde brachial arteriography indicated an arteriovenous malformation in the right occipital region (Fig. 3). The entire vascular malformation was removed and the postoperative course was uneventful. Naturally, in determining surgical treatment in cases of epilepsy, consideration must be given not only to such morphological examinations as neuroradiological studies, but also to functional analysis through electroencephalography and analysis of the seizure pattern. Lastly, epileptic attacks occurring in the wake of minor or moderate head injuries will be discussed. Generally, in the posttraumatic period, there is no close relationship between clinical symptoms, i.e., the presence or absence of epileptic seizure and electroencephalographic findings especially
Fig. 3: Right retrograde brachial angiography, lateral view.
among children. Therefore, careful determination should be practiced in the administration of antiepileptic drugs. In the future, ideal therapeutic criteria, especially concerning patients demonstrating epileptic abnormalities in electroencephalograms of the posttraumatic period, should be established.
Discussion from the Neurosurgical Point of View Kazuo Takeuchi, M.D. Department of Neurosurgery, Kyorin University School of Medicine, Tokyo
In Japan, not a few epileptic patients have been and are being treated at neurosurgical clinics. Many have been nonsurgical epileptics in addition to patients with symptomatic epilepsy due to various organic lesions. The main reasons for this situation are as follow:
1. Many epileptic patients do not wish to go to psychiatric clinics, and the number and distribution of neurological or seizure clinics is still insufficient. 2. Many patients believe epileptic seizures are of traumatic origin, even in cases of minor head injuries. 3. Many patients desire surgery instead of annoying and time-consuming medical treatment. In fact, not a few patients believe surgery can radically treat most cases of idiopathic epilepsy. However, Japanese neurosurgeons routinely prescribe antiepileptics for most patients, as do doctors in other fields. Also, from the neurosurgeons’ point of view, the necessity for surgery in epileptic cases is more apt to be detected in neurosurgical clinics than in clinics of other fields. Naturally, some selected cases of so-called intractable epilepsy, where conventional application of antiepileptics has been of little value, have been treated surgically by certain neurosurgeons. The recent introduction of computerized tomography (CT) is worth mentioning in Received for publication June 25, 1979.
regard to surgical treatment of epilepsy from the neurosurgical point of view. At outpatient clinics, adjuvant examinations of epileptic seizure cases to screen surgical cases include plain craniography and electroencephalography, with radionuclide brain scintiscanning sometimes added if necessary. These are non-invasive methods and more convenient in regard to infant and aged patients. However, such primary screenings are unable to detect all cases requiring surgery as there may be some false negative findings. Secondary adjuvant examinations, namely cerebral angiography, air study, etc., which are more invasive methods of examination, were the only methods available prior to the introduction of CT. Computerized tomography also is non-invasive and essential in primary screening. However, under existing circumstances it cannot be applied to all epileptic outpatients, and only selected cases are subjected to m. The frequency of abnormal CT findings among epileptic patients as reported by neurosurgical clinics in Japan are shown in Table 1. It is rather high, ranging from 8 to 52%. The wide range of frequency may depend on the variety of patients at each clinic. Such abnormal CT findings were found not only at the disease’s onset but also in later stages during follow-up. The frequency of abnormal CT findings in cases of focal seizure is about twice that in cases of general seizure. During the past 18 months, CT examinations have been carried out in 176 cases where the patient’s complaint on his first
K. Takeuchi
414
visit to the outpatient section of the author's clinic has chiefly been at least an epileptic seizure. The frequency of abnormal CT findings has in general reached 52%, as shown in Table 2. Among these cases were 22 (24%) cases of brain tumor and three cases of arteriovenous malformation, as well as other surgical cas& such 'as congenital arachnoid cyst. In other words, about 30% of the cases demonstrating abnormal CT findings require neurosurgical treatment. Such cases were more frequent among patients over 20 years of age, reconfirming the fact that epilepsy among elder age groups should be examined from a neurosurgical point of view. In addition, it is possible that such abnormalities as detected
Table 1:
by CT and which cannot be treated with existing neurosurgical techniques may receive surgical attention in the not too distant future. An illustrated case of neurosurgical epilepsy will be described. A 69-year-old male
CT Findings in Epileptic Patients -..-
Frequency of Abnormal CT (%) 8.7
40
Repcrted by Noya et. a1 Nakajima e t . al. Mori e t . al. Kobityashi et. d.
(73/842)
(32/ 80)
44.7 (17/ 38) 25 (42/160) 16 (13/ 80) General
seiz. 36 (29/ 80) Focal seiz. 52 (91/176) Takeuchi et. 01 45 (67/148) General
seiz. 86
Fig. 1 : Computerized tomography (with contrast enhancement)
(24/ 28) Focal seiz.
Table 2:
CT Findings in Epileptic Patients (June '77-Oct. '78) CT Positive
Seizure Focal seizure < 19 years > 20 years General seizure < 19 years > 20 years Total
Brain Tumor
Miscellaneous 0
5
I ' 4
3
17 2 15 22
19
0 0
Total
24
28
11 8 47
0 3
3
CT Total Negative
91
4 0
81
67 25 22
66
4 12 12
148
27
40
40
41 85
16 12 67 81 176
Prom Neurosurgical Point of View
Fig. 2:
415
Radionuclide brain scintigraphy, right lateral and posterior.
was first seen at our outpatient clinic due to the recent occurrence of generalized convulsive seizure. General neurological examinations, plain craniograms, and electroencephalograms revealed no peculiarities, but contrast-enhanced CT and radionuclide brain scintigrams uncovered a massive lesion in his right occipital region (Figs. 1 and 2). He was hospitalized, and a carefully performed right retrograde brachial arteriography indicated an arteriovenous malformation in the right occipital region (Fig. 3). The entire vascular malformation was removed and the postoperative course was uneventful. Naturally, in determining surgical treatment in cases of epilepsy, consideration must be given not only to such morphological examinations as neuroradiological studies, but also to functional analysis through electroencephalography and analysis of the seizure pattern. Lastly, epileptic attacks occurring in the wake of minor or moderate head injuries will be discussed. Generally, in the posttraumatic period, there is no close relationship between clinical symptoms, i.e., the presence or absence of epileptic seizure and electroencephalographic findings especially
Fig. 3: Right retrograde brachial angiography, lateral view.
among children. Therefore, careful determination should be practiced in the administration of antiepileptic drugs. In the future, ideal therapeutic criteria, especially concerning patients demonstrating epileptic abnormalities in electroencephalograms of the posttraumatic period, should be established.
