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CLINICAL AND DIAGNOSTIC FEATURES AND
EFFECTIVENESS OF SURGICAL TREATMENT OF MESIAL
TEMPORAL LOBE EPILEPSY
Bobur Abduvoyitov
Samarkand state medical university, Samarkand, Uzbekistan
https://doi.org/10.5281/zenodo.16017521
ARTICLE INFO
ABSTRACT
Received: 09
th
July 2025
Accepted: 15
th
July 2025
Online: 16
th
July 2025
,
Despite certain successes in the treatment of epilepsy, primarily
associated with the active development of pharmacology, in
30% of cases its resistant course is noted, especially focal forms
of temporal epilepsy. One of the main causes is mesial temporal
sclerosis (MTS), considered an absolute epileptogenic substrate,
not amenable to conservative treatment in 90-92% of cases.
Surgical treatment seems to be the only method that helps
improve the quality of life of such patients. However, the
percentage of surgical care for epilepsy remains low.
Structured information on clinical manifestations, diagnostic
methods, approaches to surgical treatment and its outcomes
should contribute to understanding the problem among
specialists. Data on the effectiveness of operations in patients
with drug-resistant epilepsy can help in timely provision of
high-tech care to patients with mesial temporal epilepsy.
KEYWORDS
Mesial temporal sclerosis,
hippocampal
sclerosis,
drug-resistant
epilepsy,
diagnosis of hippocampal
sclerosis,
surgical
treatment of epilepsy.
INTRODUCTION
Epilepsy is a serious medical and social problem worldwide. About 70 million people
suffer from this disease regardless of gender, race, age or geographic boundaries [1]. In
Europe, about 6 million people suffer from epilepsy, in Russia there are up to 500,000
registered cases [2]. Diagnosis and treatment of this disease are resource -intensive, which
may be the reason for the significant spread of data between the epidemiological indicators of
the regions [1]. Patients who continue to have epileptic seizures despite drug therapy suffer
from cognitive and mental disorders, and also have a high risk of injury and sudden death
(SUDEP – sudden unexpected death ) . The most common form of epilepsy is temporal,
accounting for 60–70% of focal epilepsies [3]. There are two main forms of temporal epilepsy:
mesial ( syn . limbic , paleocortical ) and lateral ( syn . neocortical ). This division is not
accidental: despite the anatomical affiliation with the temporal lobe, the lateral and
mediobasal sections have fundamental differences functionally and morphologically . A third
of patients with temporal epilepsy do not have a satisfactory response to drug therapy [4].
Mesial temporal epilepsy (MTE), associated with structural changes in the hippocampal
amygdaloid complex, occurs in 60–65% of patients with drug -resistant temporal epilepsy.
The pathomorphological substrate of MVE is usually hippocampal sclerosis . The second most
common is amygdala damage, and the third is the uncus [5]. In the presence of such
epileptogenic anatomical lesions, drug resistance approaches 90 –92% [4]. Back in 2003, the
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American Academy of Neurology published guidelines for the management of patients with
drug-resistant temporal lobe epilepsy , which indicated that if two antiepileptic drugs (AEDs)
in adequate therapeutic doses are ineffective, surgical treatment as early as possible is
recommended . In 2012, based on a multicenter randomized trial (J. Engel et al .) these
recommendations were confirmed. However, statistical data still show a rather low
percentage of surgical care for epilepsy even in developed countries [6]. Nevertheless, the
most complete possible awareness of doctors about the effectiveness of surgical treatment of
patients with drug-resistant epilepsy can help to provide timely high-tech care to this
category of patients. Anatomo – histological pections of the temporal lobe. Due to the complex
structural and functional organization of the temporal lobe, damage to individual anatomical
areas is accompanied by various clinical manifestations.
Thus, the mediobasal parts of the temporal lobes are part of the limbic system of the
brain. They include morphological substrates of memory ( hippocampus , dentate gyrus) and
mental functions ( amygdala), as well as structures of the olfactory cortex (uncus, insula) and
the pathways of the visual analyzer [7]. Close interconnection of the limbic system with the
structures of the diencephalon leads to pronounced vegetative manifestations when it is
irritated (cingulate gyrus, parahippocampal gyrus, hippocampus, dentate gyrus). The internal
part of the temporal lobe, primarily the hippocampus, in contrast to the external, has a
different histological structure. It includes the old ( paleocortex ) and ancient cortex
(archicortex ) , which have a three-layer cellular architectonics. The cells are located in the
form of layers of polymorphic cells, pyramidal neurons and a molecular layer. The border
between the outer and inner parts of the temporal lobe is the parahippocampal gyrus, which
has a transitional structure [8]. Cortex The hippocampus is divided into 4 segments by cellular
structure: CA1–CA4. Segmental differences consist of the number and size of pyramidal cells.
Fields CA1 and CA3 are the main segments of the hippocampus. In fields CA1 and CA2, 2
layers of small pyramidal cells are closely located, continuing into a layer with large, relatively
sparsely located cells of segment CA3, the axons of which provide collaterals Schaffer .
Collaterals, in turn, contact the pyramidal cells of the CA1 segment, creating the main
association pathway. The CA4 segment consists of small pyramidal cells and is surrounded by
the gray matter of the dentate gyrus. A granular layer of cells passes under the hilus of the
dentate gyrus of the hippocampus . Below is the molecular layer of the hippocampus [9]. In
MIS, selective loss and degeneration of pyramidal cells in different segments of the
hippocampus is observed; in addition, glial changes are detected. It should be noted that the
term "hippocampal sclerosis" implies the presence of pronounced gliosis in its tissue. In some
cases, the resulting reactive gliosis can be accompanied by characteristic electrophysiological
changes, but due to insufficient expression of tissue restructuring in the hippocampal
segments, such changes are not considered mesial sclerosis [10]. The International League
Against Epilepticism (ILAE) proposed to classify MBC based on the histological picture. The
main advantage of this classification is its universality and ease of use. Standard and
accessible methods of staining brain tissue are used. This classification method allows us to
distinguish between a typical histological picture (MBC type 1) and an atypical one (MBC
types 2, 3). The advantage of this system is the universal possibility to compare the results of
different clinics and to correlate them with neuroimaging data [11]. Type 1 is the most
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common (60–80% of cases). It is characterized by the loss of more than 80% of pyramidal
cells in the CA1 field of the hippocampus, combined with lesser cell loss and gliosis in the
remaining segments. Total sclerosis type 1 also includes destruction of the dentate gyrus and
more extensive damage to segments other than CA1. Type 2 is characterized by neuronal
degeneration and gliosis predominantly in the CA1 field. Type 3 indicates a pathological
process in the CA4 segment. The term " gliosis " in this classification is used for small glial
changes, most often in the subgranular layer. diagnostics of mesial and jugular sclerosis.
Clinical semiotics of epileptic seizures provides important information about the possible
localization and lateralization of the epileptic focus. According to the 2017 ILAE classification
of epileptic seizure types [12], MVE can manifest itself in various types of seizures: focal with
preserved awareness (consciousness), focal with impaired awareness, and focal with
transition to bilateral tonic-clonic seizures. In terms of kinematics, seizures most often occur
in the form of focal motor seizures with impaired awareness and automatisms (oralimentary,
gestural or ambulatory) or focal non-motor seizures with impaired awareness and cessation
of action. Sometimes focal sensory disturbances occur in the form of vegetative-visceral
abdominal auras, less often olfactory auras (about 1% of all auras) [13], which can precede
the seizure or occur in isolation. Patients often suffer from focal motor seizures evolving into
bilateral tonic-clonic seizures. Progress in neuroimaging technologies has a significant impact
on expanding the possibilities of diagnostic search for etiologic factors of epilepsy, as well as
in preoperative preparation and evaluation of the results of surgical treatment of all types of
epilepsy [14]. Videoelectroencephalographic monitoring (VEM) and high-resolution magnetic
resonance imaging (MRI) are indispensable diagnostic tools for identifying and localizing
pathological foci. VEM is highly informative and is currently considered the standard of
preoperative examination.
The purpose of VEM in diagnosing MWS is both recording epileptiform patterns and
excluding pathologies disguised as epilepsy. From 4 to 10% of patients examined before
surgery have comorbid psychogenic seizures, which may progress after surgery [15]. The
method also helps to confirm existing diagnostic data and identify other possible
epileptogenic foci. Neurophysiological patterns recorded by an electroencephalograph allow
localizing the pathological source and indicate the nature of epileptiform activity and its
representation. During long-term patient monitoring, the main array of data obtained is the
recording of interictal activity. However, the “gold standard” is the recorded ictal activity
during seizures habitual for the patient in order to identify the zone of initiation of the
paroxysm [15]. For this purpose, a daily or multi-day VEM can be used, during which it is
envisaged to cancel or reduce existing drug therapy to increase the likelihood of an attack
occurring during the study, and functional provocative tests are also carried out. Classical MRI
with a targeted study of the structures of the temporal lobes when mesial temporal sclerosis
demonstrates a decrease in the volume of the hippocampus. This zone has a hyperintense
signal in the T2 mode. An increase in signal intensity may indicate an increased content of
water molecules in glial tissue [16]. Often, MRI shows atrophy of other parts of the limbic
system associated with hippocampal sclerosis. It should be oted that routine MRI is often
insensitive to hypersclerotic changes in the hippocampus. First of all, this is due to the rather
wide slice step, which is more than 5 mm in survey studies [17]. In this regard, optimized
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high-resolution MRI is used to visualize hippocampal sclerosis . The minimum slice thickness
according to special epiprotocols, which is 0.6–2 mm, in a large percentage of cases allows
obtaining sufficient information for visualizing the SWS. Nevertheless, about 30% of drug -
resistant epilepsies remain MR-negative [18]. Identification of pathological lesions, especially
focal cortical dysplasia (FCD) and hippocampal sclerosis , can be significantly improved using
the latest high-field MRI with a magnetic field strength of 7 Tesla. However, this equipment
has not yet been introduced into clinical practice, so protocols, modes and analysis
capabilities are currently being improved based on existing MRI scanners with a magnetic
field strength of 1.5–3 Tesla [18]. Data obtained in scientific studies of patients with MIS using
high-field MRI with a power of 7 Tesla have a strong correlation with the results of
histological analysis. The sensitivity and specificity values of the detected changes reached
100% [19]. FLAIR (Fluid attenuation inversion recovery) and GRE (gradient-recalled echo) on
a high-field tomograph allow us to identify foci of FCD that are not detected at
normal powers in one third of cases, but small foci of gliosis still remain undetected. Quite
often, positron emission computed tomography (PET/CT) is used to diagnose MWS.
In the case of the presence of an epileptogenic zone, according to PET with
18F-FDG (fluorodeoxyglucose), hypometabolism is detected in this area. It is noteworthy that
not only the temporal lobe area is involved in this process, but also that hypometabolism
often spreads to the insula, frontal lobe, perisylviary region and thalamus. Hypometabolism is
more pronounced in right-sided MWS than in left-sided process. Contralateral
hypermetabolism, which can be considered as a compensatory mechanism. Moreover, it is
more often detected in patients with left-sided MBC and in women. Based on the available
data, it can be concluded that MBC is not only a focal lesion, but also a widely integrated,
structurally altered brain tissue affecting other areas of the brain [20]. In cases where there is
insufficient data on the localization of the lesion, or when the results of non -invasive
diagnostic methods, resort to invasive electroencephalography ( EEG). Invasive EEG can be
performed using subdural electrodes (plates, grids) or using deep electrodes (stereo-EEG).
Both options are effective and give good results. VEM with invasive electrodes allows
localizing a clear focus of epileptiform activity in a certain area of the brain. In the work of M.
Hupalo et al . (2017) conducted an analysis of studies of 62 patients with drug-resistant
epilepsy. Among them, VEM, conducted with scalp electrodes, made it possible to determine
the focus of pathological activity in 69% of cases. The remaining patients did not have data on
the clear localization of the epileptogenic zone, and subsequently 53% of these patients
underwent diagnostics using deep electrodes, 31% of patients - with the help of subdural and
the remaining 16% - with the help of sphenoid electrodes.
As a result, epileptiform activity was "localized" in all patients [21]. During surgery for
hippocampal sclerosis, invasive EEG is also used with the help of electrode plates
electrocorticography, ECoG, when the bioelectrical activity of the brain is recorded directly
from the cerebral cortex. Thanks to such methods, the most accurate localization of
epileptiform activity is revealed to indicate the boundaries of resection. This allows for
maximum excision of the pathological substrate while preserving healthy brain tissue. In most
cases, at the final stage of resection of sclerotic structures, a decrease in the representation
and intensity of epileptiform activity is observed on ECoG [22]. In our country, intraoperative
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ECoG has been actively used in the last decade, which significantly improves the outcomes of
surgical treatment of mesial temporal epilepsy [23]. In some cases of temporal epilepsy, the
source of epileptic activity is not one focus. Thus, the primary focus can be located in the
lateral cortex, and changes in the medio -basal regions are formed secondarily relative to it.
This pathology occurs with great variability in 9-30% of patients with temporal epilepsy [24].
In the progressive uncontrolled course of monotemporal epilepsy, an independent epileptic
focus (“mirror focus”) is formed in 17-30% of patients contralateral hemisphere [25]. In this
case, we are faced with the problem of bitemporal epilepsy, which often requires the use of
invasive diagnostic methods, as well as several other approaches to surgical treatment. In
particular, they resort to implantation of a vagus nerve stimulator or a deep structure
stimulator.
The most common types of surgical interventions for epilepsy are open resection
operations
[26].
Among
them,
anterior
medial
temporal
lobectomy
with
amygdalohippocampectomy and selective amygdalohippocampectomy are distinguished,
which are performed through transsylvian transcortical or infratemporal approaches. The
volume of resection is determined by the presence of important functional zones in the area of
intervention [27]. New surgical techniques include stereotactic radiosurgery (SRS), MRI-
guided laser interstitial thermal therapy (MgLiTT), and stereo-EEG -guided radiofrequency
thermocoagulation (SEEG- guided RFTC) [26]. Unfortunately, in some cases of drug-resistant
epilepsy, surgical intervention is impossible. Limitations may be associated with the presence
of multiple epileptogenic foci, the impossibility of localizing the focus, or the location of the
pathological substrate, which is dangerous for any surgical intervention (primarily due to the
proximity of functionally significant zones) [28]. For such patients, neurostimulation
techniques are used, including vagal stimulation (Vagus nerve stimulation (VNS), deep brain
stimulation (DBS), flexible sensory stimulation (Responsive neurostimularion – RNS).
Compared to resection and thermocoagulation techniques, neurostimulation is considered a
palliative procedure. However, it helps to reduce the number of seizures, and in exceptional
cases, even eliminates them [28]. However, there is no direct comparison of neurostimulation
techniques with each other due to methodological difficulties. outcomes of surgical
interventions. Currently, most specialists use the classification of surgical outcomes of
epilepsy treatment proposed by Jerome Engel in 1993 [29]. In accordance with it, 4 classes
are distinguished. Despite the widespread use of this classification among neurosurgeons and
neurologists throughout the world, it has a number of shortcomings and needs to be revised
regarding the clinical assessment of the outcomes of surgical treatment. Thus, in this
classification, class I includes both the complete absence of attacks and the persistence of
focal attacks, and this group also takes into account the recurrence of attacks after the
discontinuation of AEDs. There is also no differentiation by attack types and no display of the
dynamics of attack frequency relative to the period before surgical treatment. Therefore, ILAE
(2001) proposed a draft of a new classification of surgical treatment outcomes that takes into
account clinical and anamnestic data [30] (Table 2). However, many authors use both
classifications in their studies. According to the results of 389 resection operations performed
by B. Mathon et al. (2017) obtained comparable results using both selective
amygdalohippocampectomy and anterior temporal lobectomy. The authors achieved the
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Engel I outcome in 83.7% of cases, of which Engel Ia – was found in 57.1% of patients. The
first histological type was found in 75.3% of patients, the second type – in 18.7 %, the third
type – in 1.2% of patients. In 70% of cases (62–83%), long-term absence of attacks after
resection surgery was noted [31]. In the study by Ç. Özkara et al. (2007) analyzed the results
of 165 cases of open surgical interventions, among which 138 patients underwent selective
resection via the transsylvian approach, and 27 patients underwent anterior temporal
lobectomy. The results were assessed using the Engel and ILAE scales. The outcome according
to Engel I by the end of the observation was noted in 72.1%, ILAE class Ia – in 52.7%. The
period without auras and attacks by the end of the 2nd year, 5 and 8 years after the operation
lasted in 89.6, 78.8 and 62.5%, respectively. Discontinuation of antiepileptic therapy was
achieved in 41 patients. Complications in the form of hemiparesis were diagnosed in 4
patients, aphasic disorders – in 2 people [32].
In a study by Russian authors (V.V. Krylov, A.B. Gekht , I.S. Trifonov et al ., 2016), who
studied the results of resective surgery in 59 patients using the Engel scale , class I outcomes
were observed in 69% of patients, of which Engel I was achieved in 42%, class II outcomes
were observed in 19% of patients, and unfavorable outcomes were noted in 12% of cases. The
most common complication of these types of operations was hemianopsia (62.7%), which in
most cases did not bother patients [33]. According to another study (V. R. Kasumov, V. P.
Bersnev, R. D. Kasumov , 2011), in patients with drug-resistant epilepsy, divided into groups
depending on the type of surgical treatment methods used (transcortical selective
mygdalohippocampectomy and selective amygdalohippocampectomy, supplemented by
subpial transections in the functionally significant zone), the effectiveness of surgical
treatment with a combination of transcortical selective amygdalohippocampectomy and
multiple subpial transsections was significantly higher than with isolated transcortical
selective amygdallogippocampectomy. The combined use of the above-mentioned surgical
treatment options allows for positive treatment results in 77.8% of cases, while with isolated
selective transcortical amygdalohippocampectomy they account for 66.7% of observations
[34]. A frequent complication after surgical interventions for MVC is a violation of the visual
fields. In most cases, as a result of damage to the Meyer loop (the temporal part of the optic
radiation), superior quadrant hemianopsia develops. In a study by B. Schmeiser et al. (2017)
assessed the visual fields in 276 operated patients, revealing visual field impairments in 73%
of cases. Significant impairments in everyday life (e.g., difficulty driving a car, crossing the
road, reading) were found in 46% of patients. This defect was least common when choosing a
subtemporal approach [35]. In 2016, a meta-analysis of surgical treatment of temporal lobe
epilepsy performed using stereotactic radiosurgery. The study was based on 13 scientific
papers, including a total of 165 cases of surgical treatment with subsequent observation of
patients in the range from 6 months to 10 years. In this study, the Engel I result was
interpreted as the absence of seizures. On average, by 14 months after surgery, the Engel I
result was achieved in 50.9% of patients [36]. Other SRS outcomes were not published in this
study. In our country, this method of treating epilepsy has begun to be used relatively
recently. According to domestic studies (V.V. Krylov, V.A. Rak, A.S. Tokarev, 2021), all patients
operated
on
using
stereotactic
radiosurgery
had
previously
undergone
amygdalohippocampectomy. In patients with hippocampal sclerosis, the target of the
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intervention was the residual fragments of the amygdala , the anterior 2/3 of the
hippocampus and the underlying parahippocampal gyrus. Class I outcome according to the J.
Engel scale was observed in 1 patient (12.5%). In 4 patients (50%), the outcomes
corresponded to class II: IIA - 1 patient, IIB - 2 patients, IIC - 1 patient, unfavorable outcomes
were observed in 3 patients (37.5%). The main type of complications when using this
technique is radiation necrosis, which can subsequently form a new epileptogenic focus [37].
According to another domestic study (V. R. Kasumov , 2009), when using stereotactic
destruction of the hippocampal -amygdaloid complex, a decrease in the number of seizures
was noted in 60% of cases [38]. The quality of life of patients after SRS is better than after
microsurgery, but the delayed therapeutic effect in case of ineffective intervention and
ongoing seizures can be accompanied by a significant deterioration in the patient's condition
[39]. Among the specific complications of SRS, the main ones are visual field impairment
(17.9%) and aphasic impairments such as acoustic amnestic aphasia (14.9%) [36 ]. Laser
interstitial thermal therapy involves the use of laser light to heat and destroy the affected
tissue under the control of MR thermography . With the help of MRI, it is possible to observe
the ablation zone with a diameter of 5 mm to 20 mm [40]. B. Youngerman et al . (2020)
described the outcomes of the MgLiTT technique in an analysis of 13 scientific papers that
included 519 cases . Patients were followed for at least 1 year. The absence of seizures with
laser amygdalogippocampectomy was achieved in the range from 36 to 62% of cases . The
largest study, including 562 patients with hippocampal sclerosis operated on using the
MgLiTT technique , shows an Engel I result of 58 % [41]. These studies demonstrate a
comparatively worse result with MgLiTT than with open resection techniques. Practice shows
that some patients do not agree to open surgery due to the upcoming trepanation and wide
resection, despite the progressive course of the disease. In such cases, according to R. Gross et
al . (2015), R. Wicks et al . (2016), the chance to improve the patient's quality of life with
minimally invasive techniques should be used. The risk of acoustic-mnestic aphasia in laser
hippocampectomy is lower than in resection surgeries . J. Kang et al . (2015) indicate that with
this technique, verbal memory impairment will manifest itself more often while maintaining
the contextual nature of memorization [42]. The cognitive state of patients after the
intervention was also comparatively better than with resection surgery [40]. The most
common complication (3–9% of cases) in laser hippocampectomy was contralateral upper
quadrant hemianopsia. Summarizing the positive qualities of MgLiTT, we can note low
invasiveness, a small number of serious complications, a low probability of cognitive decline
in the patient, the possibility of repeating the surgery and rapid recovery of patients after the
intervention [42]. The goal of radiofrequency thermocoagulation under stereo -EEG
navigation is the destruction of the epileptogenic focus using a radiofrequency generator.
SEEG- guided RFTC is usually used in hippocampal sclerosis, FCD, tuberous sclerosis [43].
Analysis by H. Catenoix et al . (2018) demonstrates the outcomes of destruction without using
the Engel scale. The work assessed 251 cases of drug-resistant epilepsy for the period 2004–
2013. Complete freedom from seizures during the first year was achieved in 23% of patients
(pooled indicator ). Improvements were achieved in 68% of operated patients [43].
Neurological deficit was 2.5% of cases. Obviously, the outcomes of resection surgeries are
much better, but SEEG- guided RFTC can be the method of choice in cases of drug - resistant
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epilepsy when open surgery is not possible. The outcomes of surgeries in patients who
underwent invasive EEG monitoring as part of preoperative diagnostics show some
differences depending on the chosen technique. The outcomes of Engel class I surgeries were
noted in 57.3 % of cases using subdural electrodes. Complete relief from seizures was
achieved in 55.9% of patients. When using deep electrodes, Engel class I was observed in
71.6% of patients, and a seizure - free period after surgery was observed in 64.7% of cases.
Thus, the use of stereo-EEG has proven to be a more accurate method for verifying an
epileptogenic focus compared to the use of subdural electrodes [44]. L. Willems et al . (2019)
in a group of 18 patients (168 electrodes were used) who underwent stereo-EEG, calculated
that the risk of severe complications (bleeding, edema, infection) increases by 1.2% with each
new electrode.
Complications such as headache, subfebrile fever can occur 4.2% more often [45].
With the development of neuroimaging, electrophysiological and genetic research methods,
the issues of epilepsy, as well as the effectiveness of surgical treatment and its outcomes, are
becoming increasingly relevant.
In the updated classification of epileptic syndromes (ILAE, 2017), the term
"symptomatic epilepsy" is replaced by "structural epilepsy", which suggests a personalized
approach to verifying the epileptogenic zone. This leads to a more favorable outcome of the
disease and a reduced risk of relapse when therapy is discontinued.
At present, there are sufficient methods for diagnosing MIS, which makes it possible to
standardize and introduce into clinical practice in drug-resistant epilepsy a universal
algorithm for performing preoperative verification of the epileptogenic zone. Using non -
invasive diagnostic methods (careful collection of anamnesis, seizure semiology, video-EEG
monitoring, high - resolution MRI , PET/CT with glucose), and if there is insufficient
information, resort to invasive methods implantation of subdural electrodes or stereo-EEG).
Depending on the surgical technique used, the outcomes of operations can vary significantly.
Resection surgery is preferable, since it has the most favorable outcomes in terms of getting
rid of seizures and the possibility of subsequent cancellation of drug therapy. However, its
disadvantages include the risk of developing neurological and cognitive deficit. Minimally
invasive methods are often used, the essence of which lies not so much in the destruction of
the epileptic focus as in its disconnection from neighboring structures. This technique is
preferable in young patients with MBC of the dominant hemisphere due to a lower percentage
of postoperative complications. Surgical treatment of resistant epilepsy in MBC in most cases
leads to an improvement in the quality of life of patients. Awareness of possible options for
providing care to patients with drug-resistant epilepsy, including the outcomes of surgical
treatment, should facilitate adequate decision-making on the tactics of treating the patient.
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