Chirurgie des épilepsies partielles pharmaco-résistantes de l'adulte

The safety and efficacy of the surgical treatment of drug-resistant partial epilepsy on seizure control and quality of life has been well established. Surgical candidates are selected based on clinical, neurophysiological and imaging data. The major causes of intractable partial epilepsy are hippocampal sclerosis (responsible for mesial temporal lobe epilepsy), low-grade developmental tumors - DNTs and gangliogliomas, focal cortical dysplasias, vascular lesions and scars. Presurgical investigations include video-EEG, anatomical and functional neuroimaging, neuropsychological and psychiatric assessment, performed in a reference center. Depth electrode implantation and recordings (SEEG) may be necessary to localize the brain area responsible for seizures and to set a surgical strategy. Various surgical techniques include resective procedures-temporal, extra-temporal or in functional areas - focal destructive procedures, disconnection and neuromodulation procedures. Multidisciplinary postoperative care includes antiepileptic drug management, care for comorbid conditions and social rehabilitation. Surgical results primarily depend on the etiology of the epilepsy: a seizure-free outcome is observed in 60% to 80% of patients undergoing surgery for mesial temporal lobe epilepsy, in more than 80% of patients after resection of a low-grade tumor and more than 90% after resection of a focal cortical dysplasia. Seizure relief is associated with a significant improvement in quality of life. Memory worsening after temporal lobe surgery may be anticipated using clinical and functional imaging data. Future issues of epilepsy surgery include a quicker access to an epilepsy surgery center, an improvement of seizure outcome after temporal lobe surgery, and preoperative as well as intraoperative identification of MRI-negative epileptogenic lesions.