Nicht-invasive prächirurgische Epilepsiediagnostik

Zusammenfassung

Als Kandidaten für eine epilepsiechirurgische Behandlung gelten Patienten, die pharmakoresistent sind und an einer Epilepsie fokalen Ursprungs leiden. Der epilepsiechirurgische Eingriff darf kein zusätzliches, wesentliches neurologisches Defizit herbeiführen. Eine nicht-invasive prächirurgische Epilepsiediagnostik lässt sich bei > 90 % aller OP-Kandidaten durchführen. Die nicht-invasiven Verfahren stützen sich im Kern auf die klinische Anfallsbeschreibung, das Oberflächen-EEG mit interiktaler Aktivitätsaufzeichnung und Anfallsaufzeichnungen sowie die strukturelle und funktionelle kernspintomographische Diagnostik. Begleitend werden neuropsychologische Testverfahren angewendet. Primär soll hierdurch eine Gefährdung des Patienten bezüglich postoperativer kognitiver Defizite erkannt werden. Zudem ergeben sich zusätzliche Hinweise auf die Lokalisation des epileptischen Herdes. Hirnmetabolisch bildgebende Verfahren wie das PET und SPECT liefern supplementäre Informationen. Sie sind immer dann wichtig, wenn Klinik, EEG und MRI widersprüchliche Aussagen liefern oder keinen umschriebenen Anfallsherd erkennen lassen. Die resektiven Verfahren am Temporallappen und extratemporal sowie die Hemisphärektomie führen bei 50 - 80 % der Patienten zur Anfallsfreiheit. Die Kallosotomie, die multiplen subpialen Transektionen und die Stimulation des Nervus vagus sind palliative Verfahren, die eine Verbesserung der Anfallssituation, aber keine dauerhafte Anfallsfreiheit herbeiführen können. Operative Verfahren haben einen festen Platz in der Epilepsietherapie und sind bei 3 - 5 % aller Epilepsiepatienten anwendbar. Im Gegensatz zur Pharmakotherapie können sie kurativ sein. Eine prächirurgische Epilepsiediagnostik sollte in ausgewählten Zentren stattfinden, da sie zeit- und kostenintensiv ist und ein entsprechend erfahrenes Team benötigt. Die nicht-invasiven Verfahren bergen keine relevante gesundheitliche Gefahr in sich. Geeignete Kandidaten sollten früh zugewiesen werden. Dies geschieht letztlich auch unter dem Aspekt, dass therapieresistente Epilepsiepatienten einen Großteil der Kosten dieses Krankheitsbildes verursachen und sich ein günstigeres Kostenprofil nach epilepsiechirurgischem Eingriff ergibt [1].

Abstract

Epilepsy patients with medically intractable focal seizures are considered candidates for surgical treatment. In addition, the risk for substantial new neurological deficits due to surgery must be low. Nowadays, non-invasive presurgical evaluation may be performed in more than 90 % of all patients. The fraction of patients in whom invasive evaluation is performed varies between epilepsy surgery centers. Preselection of patients and techniques considered to be essential for the evaluation by the investigators appear to be the two most important factors affecting this decision. It is essentially based on the clinical seizure semiology, scalp-derived interictal EEG and EEG/Video recordings of seizures as well as morphological and functional MRI. Neuropsychometric evaluation may provide supplementary data as to the location of the epileptogenic zone and identify patients at risk for postoperative cognitive impairment. PET and SPECT imaging may provide additional data to localize or lateralize the epileptogenic zone, especially if results from other methods are conflicting or in the absence of an epileptogenic lesion. With resective surgery in the temporal lobe or extratemporal brain areas complete seizure control may be achieved in approximately 50 - 80 % of all patients. Corpus callosotomy, multiple subpial transactions and vagal nerve stimulation are palliative methods. With these methods worthwhile improvement but not long-term seizure control may be achieved. Epilepsy surgery is a well-established potentially curative treatment applicable in 3 - 5 % of all epilepsy patients. Non-invasive presurgical evaluation should be performed in specialized centres with access to all necessary diagnostic methods and a high level of experience. Non-invasive presurgical evaluation does not bear any relevant risk for the patient and should be performed early in the course of the disease. Epilepsy surgery has been proven to be a cost efficient treatment when compared to medical treatment of pharmaco-resistant epilepsy patients [1].

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