Surgical treatment of refractory epilepsy associated with space occupying lesions experience and review

Brainer-Lima, Paulo Thadeu; Rao, Sujai; Cukiert, Arthur; Yacubian, Elza Marcia Targas; Gronich, Gary; Marino Jr, Raul

doi:10.1590/S0004-282X1996000300004

Abstracts

Surgery for space occupying lesions of the brain associated with intractable epilepsy represents a special problem because relief of the epilepsy is as much an operative goal as excision of the space occupying lesion itself. This study concerns 32 patients with space occupying lesions and intractable epilepsy who underwent excision of the lesion with acute intraoperative electrocorticography guided resection of the epileptogenic focus. Of the 32 patients, 16 formed a subgroup of gangliogliomas alone. The remaining were mixed lesions, predominantly benign. The duration of seizures in these patients ranged from 2 to 30 years, and the seizure frequency varied from 1 to 300 convulsions per month. The operative procedures included temporal corticectomy, amygdalo-hippocampectomy, and extratemporal corticectomies. Twenty nine patients were in Engel class I postoperatively, and three patients were in Engel class II. The findings with gangliogliomas are also considered in a separate group. This study strongly suggests that the operative procedure under electrocorticography guidance improves seizure outcome in space occuping lesions related intractable epilepsy.

brain tumor; ganglioglioma; refractory epilepsy; electrocorticography

O tratamento cirúrgico das lesões que ocupam espaço (LOE) do sistema nervoso associadas a epilepsia intratável representa um problema clínico especial, já que tanto o tratamento da lesão como o da epilepsia são relevantes. Estudaram-se 32 pacientes com LOEs que foram submetidos a lesionectomia com margens guiadas por eletrocorticografia. Destes, 16 possuíam gangliogliomas e os restantes lesões variadas, predominantemente benignas. A duração das crises nesses pacientes variou de 2 a 30 anos e a frequência das crises de 1 a 300 por mês. Os procedimentos cirúrgicos incluíram corticectomia temporal, amigdalo-hipocampectomia e corticectomias extra-temorais. Vinte e nove pacientes estvam em grau I de Engel pós-operatoriamente e 3 em grau II. Os achados em relação aos gangliogliomas foram também estudados separadamente. Este estudo sugere que a inclusão da eletrocorticografia e da ressecção das margens epileptogênicas em pacientes com LOEs e epilepsia refratária melhoram os resultados obtidos em relação às crises.

tumor cerebral; ganglioglioma; epilepsia refratária; eletrocorticografia

Surgical treatment of refractory epilepsy associated with space occupying lesions experience and review

Tratamento cirúrgico da epilepsia refratária associada a lesões expansivas: experiência e revisão

Paulo Thadeu Brainer-Lima; Sujai Rao; Arthur Cukiert; Elza Marcia Targas Yacubian; Gary Gronich; Raul Marino Jr

Departamento de Neurologia e Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

ABSTRACT

Surgery for space occupying lesions of the brain associated with intractable epilepsy represents a special problem because relief of the epilepsy is as much an operative goal as excision of the space occupying lesion itself. This study concerns 32 patients with space occupying lesions and intractable epilepsy who underwent excision of the lesion with acute intraoperative electrocorticography guided resection of the epileptogenic focus. Of the 32 patients, 16 formed a subgroup of gangliogliomas alone. The remaining were mixed lesions, predominantly benign. The duration of seizures in these patients ranged from 2 to 30 years, and the seizure frequency varied from 1 to 300 convulsions per month. The operative procedures included temporal corticectomy, amygdalo-hippocampectomy, and extratemporal corticectomies. Twenty nine patients were in Engel class I postoperatively, and three patients were in Engel class II. The findings with gangliogliomas are also considered in a separate group. This study strongly suggests that the operative procedure under electrocorticography guidance improves seizure outcome in space occuping lesions related intractable epilepsy.

Key words: brain tumor, ganglioglioma, refractory epilepsy, electrocorticography.

RESUMO

O tratamento cirúrgico das lesões que ocupam espaço (LOE) do sistema nervoso associadas a epilepsia intratável representa um problema clínico especial, já que tanto o tratamento da lesão como o da epilepsia são relevantes. Estudaram-se 32 pacientes com LOEs que foram submetidos a lesionectomia com margens guiadas por eletrocorticografia. Destes, 16 possuíam gangliogliomas e os restantes lesões variadas, predominantemente benignas. A duração das crises nesses pacientes variou de 2 a 30 anos e a frequência das crises de 1 a 300 por mês. Os procedimentos cirúrgicos incluíram corticectomia temporal, amigdalo-hipocampectomia e corticectomias extra-temorais. Vinte e nove pacientes estvam em grau I de Engel pós-operatoriamente e 3 em grau II. Os achados em relação aos gangliogliomas foram também estudados separadamente. Este estudo sugere que a inclusão da eletrocorticografia e da ressecção das margens epileptogênicas em pacientes com LOEs e epilepsia refratária melhoram os resultados obtidos em relação às crises.

Palavras-chave: tumor cerebral, ganglioglioma, epilepsia refratária, eletrocorticografia.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Aceite: 12-abril-1996.

Dr. Arthur Cukiert - Rua Nova York 744 apto 131 - 04560-001 - São Paulo SP - Brasil.

1. Awiid I A, Rosenfeld J, Ahl J, Hahn JF, Luders H. Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome. Epilepsial 991 ;32:179-186.
2. Boon PA, Williamson PD, Fried I, Spencer DD, Novelly RA, Spencer SS, Mattson RH. Intracranial intraaxial SOLs in patients with intractable partial seizures: an anatomoclinical, neurophysiological, and surgical correlation. Epilepsia 1991;32:467-476.
3. Britton JW, Cascino GD, Sharbrough FW, Kelly PJ. Low grade glial neoplasms and intractable partial epilepsy: efficacy of surgical treatment. Epilepsia 1994;35:1130-1135.
4. Cascino GD. Epilepsy and brain tumors: implications for treatment. Epilepsia 1990;31 :S37-S44.
5. Cascino GD, Kelly PJ, Hirschorn KA. Stereotactic resection of intraaxial cerebral lesions in partial epilepsy. Mayo Clin Proc 1990;65:1053-1060.
6. Cascino GD, Kelly PJ, Sharbrough FW. Long term follow up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalogruphic results. Epilepsia 1992;33:639-644.
7. Cassaza M, Avanzini G, Broggi G. Epilepsy course in cerebral gangliogliomas: a study of 16 cases. Acta Neurochir 1989;46(Suppl): 17-20.
8. Castillo M, Davis PC, Takei Y, Hoffman JC. Intracranial ganglioglioma: MR, CT and clinical findings in 18 patients. AJNR 1990;11:109-114.
9. Courville CB, Anderson FM. Neuro-gliogenic tumors of the central nervous system: report of two additional cases of ganglioglioma of the brain. Bull Los Angeles Neurol Soc 1941 ;6:154-176.
10. Demierre B, Stichnoth FA, Hori A, Spoerri O. Intracerebral ganglioglioma. J Neurosurg 1986;65:177-182.
11. Dome HL, O'Gorman AM, Melanson D. Computed tomography of intracranial gangliogliomas. AJNR 1986;7:281 -285.
12. Drake J, Hoffman HJ, Kobayashi J. Surgical management of children with temporal lobe epilepsy and SOLs. Neurosurgery 1987;21:792-797.
13. Engel J Jr. Approaches to localization of the epileptogenic lesion. In Engel J Jr (ed). Surgical treatment of the epilepsies. New York: Raven Press, 1987:75-95.
14. Engel J Jr, Rausch R, Lieb JP, Kuhl DE, Crandall PH. Correlation of criteria used for localizing epileptic foci in patients considered for surgical therapy of epilepsy. Ann Neurol. 1981 ;9:215-224.
15. Falconer MA, Kennedy WA. Epilepsy due to small focal temporal lesions with bilateral independent spike discharging foci. J Neurol Neurosurg Psychiatry 1961 ;24:205-212.
16. Fish D, Andermnn F, Olivier A. Complex partial seizures and small posterior temporal or extratemporal structural lesions: surgical management. Neurology 1991 ;41:1781-1784.
17. Franceschtti S, Binelli S, Casazza M. Influence of surgery and antiepileptic drugs on seizures symptomatic of cerebral tumors. Acta Neurochir 1990; 103:47-51.
18. Fried I, Kim, JH, Spencer DD. Limbic and neocortical gliomas associated with intractable seizures: a distinct clinicopathological group. Neurosurgery 1994;34:815-824.
19. Garcia CA, McGarry PA, Collada M. Ganglioglioma of the brainstem: case report. J Neurosurg 1984;60:431 -434.
20. Garrido E, Becker LF, Hoffman HJ, Hendrick EB, Humphreys R. Gangliogliomas in children: a clinicopathological study. Child's Brain 1978,4.339-346.
21. Goldring S, Gregorie EM. Surgical management using epidural recordings to localize the seizure focus: a review of 100 cases. J Neurosurgery 1973 ;60:457-466.
22. Goldring S, Rich KM, Picker S. Experience with gliomas in patients presenting with chronic seizure disorder. Clin Neurosurg 1986;33:15-42.
23. Gonzalez D, Elvidge AR. On the occurrence of epilepsy caused by astrocytoma of the cerebral hemisphere. J Neurosurg 1962;19:470-482.
24. Gueneau G, Pri vat A, Drouet J, Court L. Subgranular zone of the dentate gyrus of young rabbits as a secondary matrix, a high resolution autoradiographic study. Dev Neurosci 1982;5:345-358.
25. Haddad SF, Moore SA, Menezes AH, VanGilder JC. Ganglioglioma: 13 years of experience. Neurosurgery 1992;31:171-178.
26. Hoefer PFA, Schlesinger EB, Pennes HH. Seizures in patients with brain tumors. Assoc Res Nerv Ment Dis 1947;26:50-58.
27. Ives JR, Gloor P. A lo:.g term time lapse video system to document the patient's spontaneous clinical seizure synchronized with the EEG. Electroencephalogr Clin Neurophysiol 1978;45:421-426.
28. Jabbari B, Huott AD, DiChiro G, Martin AN, Youngblood LA, Harper MG: Surgically correctable lesions solely detected by CT scan in adult onset chronic epilepsy. Ann Neurol 1980;7:344-347.
29. Johannsson GH, Rakete HL, Roessmann U. Gangliogliomas, pathological and clinical correlation. J Neurosurg 1981 ;54:58-63.
30. Jooma R, Yeh H, Privitera MD, Gartner M. Lesionectomy versus electrophysiological guided resection for temporal lobe tumors manifesting with complex partial seizures. J Neurosurg 1995;83:231 -236.
31. Kalyan-Raman UP, Olivero WC. Ganglioglioma: a correlative clinicopathological and radiological study of 10 surgically treated cases with follow up. Neurosurgery 1987;20:428-433.
32. King DW, Ajmone-Marsan C. Clinical features and ictal patterns in epileptic patients with EEG temporal lobe foci. Ann Neurol 1977;2:138-147.
33. Kirkpatrick PJ, Honavar M, Janota I, Polkey CE. Control of temporal lobe epilepsy following en bloc resection of low grade tumors. J Neurosurg 1993;78:19-25.
34. Mattson RH: Value of intensive monitoring. In Wada Ja, Penry JK (eds). Advances in epileptology: the Xth epilepsy international symposium. New York: Raven Press, 1980:43-51.
35. Moore JL, Cascino GD, Trennery MR. A comparative study of lesion resection with corticectomy with stereotactic lesionectomy in patients with temporal lobe lesional epilepsy. Epilepsia 1992; 33(Suppl 3):96.
36. Morris HH, Luders H, Hahn JF, Lesser RP, Dinner DS, Estes ML. Neurophysiological techniques as an aid to surgical treatment of primary brain tumors. Ann Neurol 1986;19:559-567.
37. Naas R, Whelan MA. Gangliogliomas. Neuroradiology 1988;22:67-71.
38. Piepmeier JM, Fried I, Makuch R. Low grade astrocytomas may arise from different astrocyte lineage. Neurosurgery 1993;33:627-632.
39. PilcherWH, SilbergeldDL. Intra operative electrocorticography during tumor resection: impact on seizure outcome in patients with gangliogliomas. J Neurosurg 1993;78:891-902.
40. Quesney LF, Gloor P. Localization of epileptic foci. Electroenceph Clin Neurophysiol I985;37 (Suppl): 165-200.
41. Rasmussen T. Surgery of epilepsy associated with brain tumors. In Purpura DP, Penry JK, Walter RD (eds). Neurosurgical management of the epilepsies. New York: Raven Press, 1975:227-229.
42. Spencer DD. Strategies for focal resection in medically intractable epilepsy. In Theodore WH (ed). Surgical treatment of epilepsy. Amsterdam: Elsevier, 1992,157-168.
43. Spencer DD, Spencer SS, Mattson RH. Intracerebral masses in patients with intractable partial epilepsy. Neurology 1984;34:432-436.
44. Spencer SS, Williamson PD, Spencer DD, Mattson RH. Combined subdural and depth electrode investigation in uncontrolled epilepsy. Neurology 1990;40:74-79.
45. Sperling MR,Cahan LD, Brown WJ. Relief of seizures from a predominantly posterior temporal tumor with anterior temporal lobectomy. Eplepsia 1989;30:559-563.
46. Sperling MR, O'Connor MJ. Comparison of depth and subdural electrodes in recording temporal lobe seizures. Neurology 1989;39:1497-1504.
47. Sutton LN, Packer RJ, Rourke LB, Bruce DA, Schut L. Cerebral gangliogliomas during childhood. Neurosurgery 1983;13:124-128.
48. Tampieri D, Moumdjian R, Melanson D, Ethier R. Intracerebral gangliogliomas in patients with partial complex seizures: CT and MR imaging findings. AJNR 1991; 12:749-755.
49. Theodore WH, Porter RJ, Penry JK. Complex partial seizures: clinical characteristics and differential diagnosis. Neurology 1983;33:1115-1121.
50. Williamson PD, Wieser HG, Delgado-Escueta AV. Clinical characteristics of partial seizures. In Engel J Jr (ed). Surgical treatment of the epilepsies. New York: Raven Press, 1994:49-63.
51. Weber JP, Silbergeld DL, Winn HR. Surgical resection of epileptogenic cortex associated with structural lesions. Neurosurg Clin N Am 1993;4:327-336.
52. Wyllie E, Luders H, Morris HH III. Clinical outcome after complete or partial cortical resection for intractable epilepsy. Neurology 1987;37:1634-1641.
53. Zentner J, Hufnagel A, Wolf HK, Ostertun B, Behrens E, Campos MG, Solymosi L, Elger CE, Wiestlar OD, Schramm J. Surgical treatment of temporal lobe epilepsy: clinical radiological and histopathological findings in 178 patients. J Neurol Neurosurg Psychiatry 1995;58:666-673.
54. Zimmerman RA, Bilaniuk LT. Computed tomography of intracerebral gangliogliomas. J Comput Tomogr 1979;3:24-30.

Publication Dates

Publication in this collection
10 Nov 2010
Date of issue
Sept 1996

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Awiid I A, Rosenfeld J, Ahl J, Hahn JF, Luders H. Intractable epilepsy and structural lesions of the brain: mapping, resection strategies, and seizure outcome. Epilepsial 991 ;32:179-186.

[2] 2. Boon PA, Williamson PD, Fried I, Spencer DD, Novelly RA, Spencer SS, Mattson RH. Intracranial intraaxial SOLs in patients with intractable partial seizures: an anatomoclinical, neurophysiological, and surgical correlation. Epilepsia 1991;32:467-476.

[3] 3. Britton JW, Cascino GD, Sharbrough FW, Kelly PJ. Low grade glial neoplasms and intractable partial epilepsy: efficacy of surgical treatment. Epilepsia 1994;35:1130-1135.

[4] 4. Cascino GD. Epilepsy and brain tumors: implications for treatment. Epilepsia 1990;31 :S37-S44.

[5] 5. Cascino GD, Kelly PJ, Hirschorn KA. Stereotactic resection of intraaxial cerebral lesions in partial epilepsy. Mayo Clin Proc 1990;65:1053-1060.

[6] 6. Cascino GD, Kelly PJ, Sharbrough FW. Long term follow up of stereotactic lesionectomy in partial epilepsy: predictive factors and electroencephalogruphic results. Epilepsia 1992;33:639-644.

[7] 7. Cassaza M, Avanzini G, Broggi G. Epilepsy course in cerebral gangliogliomas: a study of 16 cases. Acta Neurochir 1989;46(Suppl): 17-20.

[8] 8. Castillo M, Davis PC, Takei Y, Hoffman JC. Intracranial ganglioglioma: MR, CT and clinical findings in 18 patients. AJNR 1990;11:109-114.

[9] 9. Courville CB, Anderson FM. Neuro-gliogenic tumors of the central nervous system: report of two additional cases of ganglioglioma of the brain. Bull Los Angeles Neurol Soc 1941 ;6:154-176.

[10] 10. Demierre B, Stichnoth FA, Hori A, Spoerri O. Intracerebral ganglioglioma. J Neurosurg 1986;65:177-182.

[11] 11. Dome HL, O'Gorman AM, Melanson D. Computed tomography of intracranial gangliogliomas. AJNR 1986;7:281 -285.

[12] 12. Drake J, Hoffman HJ, Kobayashi J. Surgical management of children with temporal lobe epilepsy and SOLs. Neurosurgery 1987;21:792-797.

[13] 13. Engel J Jr. Approaches to localization of the epileptogenic lesion. In Engel J Jr (ed). Surgical treatment of the epilepsies. New York: Raven Press, 1987:75-95.

[14] 14. Engel J Jr, Rausch R, Lieb JP, Kuhl DE, Crandall PH. Correlation of criteria used for localizing epileptic foci in patients considered for surgical therapy of epilepsy. Ann Neurol. 1981 ;9:215-224.

[15] 15. Falconer MA, Kennedy WA. Epilepsy due to small focal temporal lesions with bilateral independent spike discharging foci. J Neurol Neurosurg Psychiatry 1961 ;24:205-212.

[16] 16. Fish D, Andermnn F, Olivier A. Complex partial seizures and small posterior temporal or extratemporal structural lesions: surgical management. Neurology 1991 ;41:1781-1784.

[17] 17. Franceschtti S, Binelli S, Casazza M. Influence of surgery and antiepileptic drugs on seizures symptomatic of cerebral tumors. Acta Neurochir 1990; 103:47-51.

[18] 18. Fried I, Kim, JH, Spencer DD. Limbic and neocortical gliomas associated with intractable seizures: a distinct clinicopathological group. Neurosurgery 1994;34:815-824.

[19] 19. Garcia CA, McGarry PA, Collada M. Ganglioglioma of the brainstem: case report. J Neurosurg 1984;60:431 -434.

[20] 20. Garrido E, Becker LF, Hoffman HJ, Hendrick EB, Humphreys R. Gangliogliomas in children: a clinicopathological study. Child's Brain 1978,4.339-346.

[21] 21. Goldring S, Gregorie EM. Surgical management using epidural recordings to localize the seizure focus: a review of 100 cases. J Neurosurgery 1973 ;60:457-466.

[22] 22. Goldring S, Rich KM, Picker S. Experience with gliomas in patients presenting with chronic seizure disorder. Clin Neurosurg 1986;33:15-42.

[23] 23. Gonzalez D, Elvidge AR. On the occurrence of epilepsy caused by astrocytoma of the cerebral hemisphere. J Neurosurg 1962;19:470-482.

[24] 24. Gueneau G, Pri vat A, Drouet J, Court L. Subgranular zone of the dentate gyrus of young rabbits as a secondary matrix, a high resolution autoradiographic study. Dev Neurosci 1982;5:345-358.

[25] 25. Haddad SF, Moore SA, Menezes AH, VanGilder JC. Ganglioglioma: 13 years of experience. Neurosurgery 1992;31:171-178.

[26] 26. Hoefer PFA, Schlesinger EB, Pennes HH. Seizures in patients with brain tumors. Assoc Res Nerv Ment Dis 1947;26:50-58.

[27] 27. Ives JR, Gloor P. A lo:.g term time lapse video system to document the patient's spontaneous clinical seizure synchronized with the EEG. Electroencephalogr Clin Neurophysiol 1978;45:421-426.

[28] 28. Jabbari B, Huott AD, DiChiro G, Martin AN, Youngblood LA, Harper MG: Surgically correctable lesions solely detected by CT scan in adult onset chronic epilepsy. Ann Neurol 1980;7:344-347.

[29] 29. Johannsson GH, Rakete HL, Roessmann U. Gangliogliomas, pathological and clinical correlation. J Neurosurg 1981 ;54:58-63.

[30] 30. Jooma R, Yeh H, Privitera MD, Gartner M. Lesionectomy versus electrophysiological guided resection for temporal lobe tumors manifesting with complex partial seizures. J Neurosurg 1995;83:231 -236.

[31] 31. Kalyan-Raman UP, Olivero WC. Ganglioglioma: a correlative clinicopathological and radiological study of 10 surgically treated cases with follow up. Neurosurgery 1987;20:428-433.

[32] 32. King DW, Ajmone-Marsan C. Clinical features and ictal patterns in epileptic patients with EEG temporal lobe foci. Ann Neurol 1977;2:138-147.

[33] 33. Kirkpatrick PJ, Honavar M, Janota I, Polkey CE. Control of temporal lobe epilepsy following en bloc resection of low grade tumors. J Neurosurg 1993;78:19-25.

[34] 34. Mattson RH: Value of intensive monitoring. In Wada Ja, Penry JK (eds). Advances in epileptology: the Xth epilepsy international symposium. New York: Raven Press, 1980:43-51.

[35] 35. Moore JL, Cascino GD, Trennery MR. A comparative study of lesion resection with corticectomy with stereotactic lesionectomy in patients with temporal lobe lesional epilepsy. Epilepsia 1992; 33(Suppl 3):96.

[36] 36. Morris HH, Luders H, Hahn JF, Lesser RP, Dinner DS, Estes ML. Neurophysiological techniques as an aid to surgical treatment of primary brain tumors. Ann Neurol 1986;19:559-567.

[37] 37. Naas R, Whelan MA. Gangliogliomas. Neuroradiology 1988;22:67-71.

[38] 38. Piepmeier JM, Fried I, Makuch R. Low grade astrocytomas may arise from different astrocyte lineage. Neurosurgery 1993;33:627-632.

[39] 39. PilcherWH, SilbergeldDL. Intra operative electrocorticography during tumor resection: impact on seizure outcome in patients with gangliogliomas. J Neurosurg 1993;78:891-902.

[40] 40. Quesney LF, Gloor P. Localization of epileptic foci. Electroenceph Clin Neurophysiol I985;37 (Suppl): 165-200.

[41] 41. Rasmussen T. Surgery of epilepsy associated with brain tumors. In Purpura DP, Penry JK, Walter RD (eds). Neurosurgical management of the epilepsies. New York: Raven Press, 1975:227-229.

[42] 42. Spencer DD. Strategies for focal resection in medically intractable epilepsy. In Theodore WH (ed). Surgical treatment of epilepsy. Amsterdam: Elsevier, 1992,157-168.

[43] 43. Spencer DD, Spencer SS, Mattson RH. Intracerebral masses in patients with intractable partial epilepsy. Neurology 1984;34:432-436.

[44] 44. Spencer SS, Williamson PD, Spencer DD, Mattson RH. Combined subdural and depth electrode investigation in uncontrolled epilepsy. Neurology 1990;40:74-79.

[45] 45. Sperling MR,Cahan LD, Brown WJ. Relief of seizures from a predominantly posterior temporal tumor with anterior temporal lobectomy. Eplepsia 1989;30:559-563.

[46] 46. Sperling MR, O'Connor MJ. Comparison of depth and subdural electrodes in recording temporal lobe seizures. Neurology 1989;39:1497-1504.

[47] 47. Sutton LN, Packer RJ, Rourke LB, Bruce DA, Schut L. Cerebral gangliogliomas during childhood. Neurosurgery 1983;13:124-128.

[48] 48. Tampieri D, Moumdjian R, Melanson D, Ethier R. Intracerebral gangliogliomas in patients with partial complex seizures: CT and MR imaging findings. AJNR 1991; 12:749-755.

[49] 49. Theodore WH, Porter RJ, Penry JK. Complex partial seizures: clinical characteristics and differential diagnosis. Neurology 1983;33:1115-1121.

[50] 50. Williamson PD, Wieser HG, Delgado-Escueta AV. Clinical characteristics of partial seizures. In Engel J Jr (ed). Surgical treatment of the epilepsies. New York: Raven Press, 1994:49-63.

[51] 51. Weber JP, Silbergeld DL, Winn HR. Surgical resection of epileptogenic cortex associated with structural lesions. Neurosurg Clin N Am 1993;4:327-336.

[52] 52. Wyllie E, Luders H, Morris HH III. Clinical outcome after complete or partial cortical resection for intractable epilepsy. Neurology 1987;37:1634-1641.

[53] 53. Zentner J, Hufnagel A, Wolf HK, Ostertun B, Behrens E, Campos MG, Solymosi L, Elger CE, Wiestlar OD, Schramm J. Surgical treatment of temporal lobe epilepsy: clinical radiological and histopathological findings in 178 patients. J Neurol Neurosurg Psychiatry 1995;58:666-673.

[54] 54. Zimmerman RA, Bilaniuk LT. Computed tomography of intracerebral gangliogliomas. J Comput Tomogr 1979;3:24-30.