Annals of Indian Academy of Neurology
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Year : 2014  |  Volume : 17  |  Issue : 5  |  Page : 1-2


Jonathan Sinay Distinguished Professor of Neurology, Neurobiology, Psychiatry & Biobehavioral Sciences Director, UCLA Seizure Disorder Center, David Geffen School of Medicine UCLA, 710 Westwood Plaza, Los Angeles, CA 90095-1769, USA

Date of Web Publication12-Mar-2014

Correspondence Address:
Jerome Engel
Jonathan Sinay Distinguished Professor of Neurology, Neurobiology, and Psychiatry & Biobehavioral Sciences Director, UCLA Seizure Disorder Center David Geffen School of Medicine at UCLA 710 Westwood Plaza, Los Angeles, CA 90095-1769
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-2327.128642

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How to cite this article:
Engel J. Preface. Ann Indian Acad Neurol 2014;17, Suppl S1:1-2

How to cite this URL:
Engel J. Preface. Ann Indian Acad Neurol [serial online] 2014 [cited 2021 Jun 21];17, Suppl S1:1-2. Available from:

Epilepsy is among the most common serious diseases of the brain, representing a health burden worldwide equivalent to breast cancer in women and lung cancer in men. It has been estimated that 80% of the people with epilepsy live in the developing world, where access to appropriate medical care is limited, and many people with epilepsy in these regions receive no treatment at all. This treatment gap has been an issue of considerable concern for the International League against Epilepsy and the International Bureau for Epilepsy, which have partnered with the World Health Organization to create the Global Campaign against Epilepsy, designed to improve knowledge, attitudes, and practices about epilepsy in these regions. Interventions are aimed at educating patients, the general public, and medical communities, and until recently, were focused on pharmacotherapy, stigma, and social services. Although surgical therapy has been accepted as an effective alternative therapy for appropriately selected patients with pharmacoresistant epilepsy for over a century, the sophisticated technical demands of presurgical evaluation were, until recently, believed to be beyond the means of countries with limited resources. The reports in this volume attest to the fact that this is no longer the case.

The modern era of surgical treatment for epilepsy began at the end of the 19 th century, and this alternative therapeutic approach became widespread with the advent of electroencephalography in the mid-20 th century. The safety and efficacy of surgical treatment was further enhanced with the use of modern neuroimaging, specifically magnetic resonance imaging and positron emission tomography, towards the end of the 20 th century. Surgically remediable epilepsy syndromes are recognized as those with a well-defined pathophysiology, localized lesions that can be surgically removed without incurring unacceptable neurological deficits, and a natural history of unresponsiveness to pharmacotherapy after failure of two appropriate antiseizure drug trials. The prototype of a surgically remediable syndrome is mesial temporal lobe epilepsy, which is also the most common form of epilepsy, and the most pharmacoresistant. Other surgically remediable syndromes include neocortical epilepsies due to structural lesions that can be easily resected, diffuse hemispheric disturbances such as Rasmussen's encephalitis, hemimegencephaly, Sturge-Weber, and large porencephalic cysts, that can be treated by hemispherectomy or hemispherotomy, and gelastic seizures with hypothalamic hamartoma, which is the source of the ictal events. Two randomized controlled trials of surgery for pharmacoresistant temporal lobe epilepsy have demonstrated its superiority over continued antiseizure drug treatment, with 64% of patients being seizure free in one trial and 85% in the other, compared to 50% of patients showing a 50% reduction in seizures in drug trial meta-analyses. The American Academy of Neurology (AAN) issued a practice parameter a decade ago recommending surgery as the treatment of choice for medically refractory temporal lobe epilepsy.

Sadly, surgical treatment for epilepsy remains arguably the most underutilized of all accepted medical treatments and represents a major treatment gap in the industrialized world. In the United States, less than 1% of patients with pharmacoresistant epilepsy are referred to epilepsy centers where surgical treatment is offered. When patients are referred for surgery, the average duration from onset of epilepsy to surgery is over 20 years. Despite the two randomized controlled trials and the AAN practice parameter, there has been no increase in the number of patients undergoing treatment in the United States since 1990, and no change in the delay to referral for patients who do receive surgical treatment.

The reason for the epilepsy surgery treatment gap in the industrialized world is unknown; it appears to be related to persistent misconceptions about who can benefit from surgery, fear of surgery, and economic issues. There are two happy exceptions to the persistent underutilization of epilepsy surgery, however. One is the increasing application of surgical treatment for infants and young children with severe life-threatening epilepsies due to structural lesions limited to one hemisphere, and the other is increasing availability of surgical treatment in countries with limited resources. In emerging economies, such as those of India, Brazil, and China, epilepsy surgery programs have been developed that offer the same degree of excellence as major epilepsy centers in North America, Europe, Japan, and Australia. The problems in these countries is access, given the overwhelming numbers of patients who might be surgical candidates, amounting to well over a million patients in India alone. Other, smaller countries are now also developing epilepsy surgery programs that offer treatment to patients with surgically remediable epilepsy syndromes that do not require expensive invasive presurgical investigations.

Economic arguments can be made that surgical treatment is more cost-effective for countries with limited resources than continued medical treatment. Now that presurgical evaluation has become sufficiently streamlined, most countries ought to be able to afford at least one epilepsy center with the capability of carrying out video-electroencephalogram (EEG) recordings and magnetic resonance imaging, which would make it possible to operate successfully on most patients with refractory temporal lobe epilepsy and neocortical epilepsy due to well-circumscribed structural lesions. Such centers could remain busy for years concentrating only on the most clear-cut surgical candidates. In order for countries with limited resources to provide effective surgical treatment for pharmacoresistant epilepsy, the primary investment needs to be in human resources, particularly appropriately trained neurologists, neurosurgeons, clinical neurophysiologists, neuropsychologists, neuroradiologists, psychiatrists, and pathologists. The goal should be to ultimately make surgical treatment available for all of the approximately 10 million people worldwide who could benefit from this alternative treatment, tremendously reducing the global financial and human cost of epilepsy.


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