Epilepsy Surgery

.: PREFACE
ÖN SÖZ
PREFACE
Prof. Dr. Galip Zihni SANUS
İstanbul Üniversitesi-Cerrahpaşa, Cerrahpaşa Tıp Fakültesi, Beyin ve Sinir Cerrahisi ABD, İstanbul, Türkiye
Article Language: TR
Modern epilepsi cerrahisi, 100 yıldan daha eski bir tarihte Macewen ve Sir Victor Horsley tarafından Epilepsili hastalar için cerrahi bir tedavi olarak tanımlanmış olmasına rağmen, yakın zamana kadar birçok kişi tarafından 'son çare' olarak görülmekte ve yalnızca 'kaybedecek bir şeyi kalmayan hastalar' için endikasyon konulmaktaydı.

Elektroensefalografinin epilepsi cerrahisine Bailey, Otfried Foerster, Altenburger, Wilder Penfield, Herbert ve Jasper'ın ortak çabalarıyla girmesinden sonra, 1930'lu yıllarda Gibbs ve Lennox, elektriksel odak üzerinde yoğunlaşma fikrini geliştirdiler. Epilepsi cerrahisindeki bu ikinci dalga, Montreal Nöroloji Enstitüsü'nün olağanüstü çalışmasıyla Penfield ve Jasper tarafından doruğa ulaşmıştır. Falconer ve arkadaşları 'en bloc' temporal lobektomiyi standardize etmiş ve yaygınlaştırmışlardır. Hemisferektominin 1923 yılında Dandy tarafından nöroşirürji prosedürü olarak tanıtılmasının ardından, epilepsi tedavisi için hemisferektomiyi ilk gerçekleştirenler McKenzie ve Krynauw oldu. Van Wagenen, 1940'ta kallosotomiye öncülük etti. Stereotaksik tekniklerin cerrahi öncesi değerlendirilmesi ise Bancaud ve Talairach'ın öncü çalışmalarıyla gerçekleşmiştir. SEEG dönemi ile birlikte preoperatif planlama döneminde epilepsi cerrahisi farklı bir boyuta taşınmıştır. Yaşargil tarafından mikrocerrahinin tanıtımı ile daha selektif operasyonlar uygulanmaya başlanmıştır. Öte yandan, modern epilepsi cerrahisinde, anterior kallosotomi gibi 'palyatif' müdahaleler, fonksiyonel hemisferektomi ve genişletilmiş multilobar rezeksizyonlar gibi geniş rezeksiyonlar, özellikle çocuklarda daha sıklıkla kullanılmaya başlanmıştır.

Görüntüleme yöntemlerindeki ilerlemeler ile ince yapısal hasarları dahî saptayabilme yeteneği, SPECT ve PET görüntülemeler ile epileptojenik 'network'ü algılamanın yanı sıra video-EEG'deki ilerlemeler ve intrakraniyal elektrot implantasyon teknikleri ile epilepsi cerrahisinde yepyeni bir sayfa açılmıştır. Yeni cerrahi teknikler ve teknolojik ekipmanın gelişmesi ile birlikte cerrahi başarı oranları artmış, komplikasyon oranları ise düşmeye başlamıştır. Nöromodulasyon alanındaki gelişmeler, radyocerrahi yaklaşımları, radyofrekans ablasyon yöntemleri, derin beyin stimulasyonları ve kranial sinir stimulasyonları ile başarılı ve alternatif birçok müdahale epilepsi hastalarında uygulanmaktadır.

Türkiye'de ise 90'lı yılların başında epilepsi cerrahisi alanında çalışmalar başlamıştır. Kliniğimizde 3 dekatlık epilepsi cerrahisi tecrübesi; ilerleryen yıllar içerisinde gerek beyin cerrahisi gerek nöroloji kliniğinde bayrağı devralan hekimler vasıtası ile epilepsi cerrahisinin modern anlamda her türlü tekniklerinin uygulandığı, dünyadaki sayılı epilepsi cerrahisi merkezleri ile eş değer öneme sahip konuma gelmiştir. Üst düzey MRG ve epilepsiye özgü çekim protokolünün uygulanması, PETMR gibi son teknolojik cihazların edinilmesi, multidisipliner yaklaşımın sağlanması, 2005 yılından sonra invaziv EEG monitörizasyonun yapılması ile epilepsi cerrahisi alanında tüm girişimler yapılabilmektedir. Bütün bunların sonucunda dünyadaki çeşitli epilepsi merkezleri ile birlikte yapılan, hatırı sayılır miktarda bilimsel yayın çıkmış ve literatüre katkı sağlanmıştır.

Belki de gelecek için en önemli gelişme, popülasyonda farkındalığı artırmak ve sağlık çalışanları arasında, tıbbi olarak dirençli fokal epilepside erken müdahalenin güvenliği ve etkinliği konusunda eğitim sağlamak olacaktır. Üçüncü basamak merkezlere erken sevkler, multidisipliner ortamda sistematik değerlendirme yollarının titiz bir şekilde uygulanması ve 3D multimodalite görüntüleme, yakın gelecekte epilepsi cerrahisindeki ilerlemenin en basit ve kesin yolu olacaktır.

Prof. Dr. Galip Zihni SANUS
Editör
Although modern epilepsy surgery was described as a surgical treatment for patients with epilepsy more than 100 years ago by Macewen and Sir Victor Horsley, until recently epilepsy surgery was considered by many to be a 'last resort' and only indicated in patients for whom 'nothing could be lost'.

Gibbs and Lennox had developed the idea of operating upon an electrical focus in the 1930s, after the introduction of electroencephalography into epilepsy surgery by the joint efforts of Bailey, Otfried Foerster, Altenburger, Wilder Penfield, Herbert, and Jasper. This second wave of epilepsy surgery was culminated by Penfield & Jasper with the extraordinary work of the Montreal Institute of Neurology. Falconer et al. standardized and popularized en bloc temporal lobectomy. After the introduction of hemispherectomy as a neurosurgical procedure by Dandy in 1923, McKenzie and Krynauw were the first to perform hemispherectomy for epilepsy treatment. Van Wagenen pioneered callosotomy in 1940. Preoperative evaluation of stereotaxic techniques was carried out with the pioneering work of Bancaud and Talairach. With the SEEG period, epilepsy surgery has moved to a different dimension in the preoperative planning period. More selective operations have been implemented with the introduction of microsurgery by Yasargil. On the other hand, in modern epilepsy surgery, 'palliative' interventions such as anterior callosotomy, wide resections such as functional hemispherectomy and expanded multilobar resection have started to be used more frequently, especially in children.

With the advances in imaging methods, the ability to detect even subtle structural damage, the ability to detect epileptogenic network with SPECT and PET imaging, as well as the advances in video-EEG and intracranial electrode implantation techniques, a brand new page has been opened in epilepsy surgery. With the development of new surgical techniques and technological equipment, surgical success rates have increased and complication rates have started to decrease. With the advances in neuromodulation, many alternative interventions such as radiosurgery, radiofrequency ablation, deep brain stimulation and cranial nerve stimulation are successfully applied in epilepsy patients.

Developments in the field of epilepsy surgery in our country began in the early 90s. The experience of 3 decades of epilepsy surgery in our clinic has become equivalent to the important epilepsy surgery centers in the world, where all kinds of modern techniques are applied in the neurosurgery and neurology clinics. New techniques and image processing methods are being applied to improve the detection of epileptogenic substrates with the use of 'high-field' MRI. Beginning with invasive EEG monitoring after 2005, all attempts are made in the field of epilepsy surgery with the acquisition of state-of-the-art devices such as PET-MR and providing a multidisciplinary approach. Thus, a considerable amount of scientific publications, contributing to the literature, have been published in collaboration with various epilepsy centers around the world.

Perhaps the most important development for the future will be to raise awareness in the population and provide education among healthcare professionals about the safety and effectiveness of early intervention in medically resistant focal epilepsy. Early referrals to tertiary centers, meticulous application of systematic assessment methods in a multidisciplinary setting, and 3D multimodality imaging will be the simplest and most definitive way to progress in epilepsy surgery in the near future.

Prof. Dr. Galip Zihni SANUS
Editor

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