Departments of Neurology, Neurobiology, and Psychiatry and Biobehavioral Sciences, and the Brain Research Institute, David Geffen School of Medicine, UCLA.
Epileptic Disord. 2019 Oct 1;21(5):391-409. doi: 10.1684/epd.2019.1091.
At the time of the first meeting of the International League Against Epilepsy (ILAE) in 1909, surgical treatment for epilepsy had been accepted as an alternative therapy for over two decades, but was rarely practiced, considered a last resort for carefully selected patients. Localization was based on ictal semiology and identification of a structural lesion. Very few papers on epilepsy surgery were presented at ILAE meetings or published in Epilepsia during the first half of the 20 century. A modest explosion in interest in epilepsy surgery at mid-century resulted from recognition that "invisible" epileptogenic lesions could be identified by EEG, especially for temporal lobe epilepsy. Epilepsy surgery received a second boost in popularity toward the end of the 20 century with the advent of structural and functional neuroimaging, and the number of epilepsy centers worldwide doubled between the first Palm Desert conference in 1986 and the second Palm Desert conference in 1992. Neuroimaging also helped to increase application of surgical treatment to infants and young children with severe epilepsies. Epilepsy surgery was accepted as standard of care for drug-resistant focal epilepsy and was well-represented at international ILAE congresses and in Epilepsia. Advances continue into the 21 century with the introduction of laser ablation, and palliative neuromodulation approaches, which have greatly increased the population of patients who can benefit from surgery. Modern presurgical evaluation techniques have also made surgical treatment possible in many countries with limited resources. Three randomized control trials now have definitively proved the safety and efficacy of epilepsy surgery, however, this alternative therapy remains under-utilized even in the industrialized world, where less than 1% of potential candidates are being referred to epilepsy centers. Furthermore, those who are referred receive surgery an average of 20 years after onset of epilepsy, often too late to avoid irreversible disability. The major challenges in realizing the full potential of epilepsy surgery, therefore, are not as much in the continued improvement of the treatment itself, as they are in addressing the treatment gap that is preventing appropriate patients from being referred to full-service epilepsy centers.
在 1909 年国际抗癫痫联盟（ILAE）的第一次会议上，癫痫的手术治疗已经被接受为一种替代疗法超过二十年，但很少实施，被认为是为精心挑选的患者保留的最后手段。定位是基于发作的半侧体征和结构性病变的识别。在 20 世纪上半叶，ILAE 会议上很少有关于癫痫手术的论文发表，也很少有发表在《癫痫》上的论文。20 世纪中叶，由于认识到 EEG 可以识别“无形”的致痫性病变，特别是颞叶癫痫，对癫痫手术的兴趣出现了适度的爆发。随着结构和功能神经影像学的出现，癫痫手术在 20 世纪末再次受到欢迎，全球癫痫中心的数量在 1986 年第一届棕榈沙漠会议和 1992 年第二届棕榈沙漠会议之间翻了一番。神经影像学也有助于将手术治疗应用于患有严重癫痫的婴儿和幼儿。癫痫手术被接受为耐药性局灶性癫痫的标准治疗方法，并在国际 ILAE 大会和《癫痫》上得到很好的体现。随着激光消融术和姑息性神经调节方法的引入，进入 21 世纪后，手术治疗的受益人群大大增加。现代术前评估技术也使得许多资源有限的国家能够进行手术治疗。三项随机对照试验现在已经明确证明了癫痫手术的安全性和有效性，然而，即使在工业化国家，这种替代疗法的应用仍然不足，只有不到 1%的潜在患者被转介到癫痫中心。此外，那些被转介的患者在癫痫发作后平均 20 年才接受手术，往往为时已晚，无法避免不可逆转的残疾。因此，要充分发挥癫痫手术的潜力，面临的主要挑战不在于继续改进治疗本身，而在于解决阻止适当患者被转介到全面服务的癫痫中心的治疗差距。
