Epilepsy: structural or functional? (original) (raw)

American Journal of Neuroradiology

The case report by Patil et al (1) in the April 1995 issue of AJNR demonstrates very poignantly the confusion about whether epilepsy is mainly a functional or mainly a structural disease. If these authors had believed epilepsy was mainly a structural disease, all that would have been required in this case was magnetic resonance (MR) imaging and a surgeon prepared to do a lesionectomy, accepting a small risk of causing a hemiplegia. However, the functional approach led to the patient's being exposed to the surgical risks of subdural grid, multiple cortical transections, and, finally, the lesionectomy. This is notwithstanding the other expensive and entirely redundant tests also carried out more than once. In this particular case there was such clear clinical location that it could be argued that even a surface electrode electroencephalogram (EEG) was unnecessary. Almost unbelievably, this case was presented as a success story for xenon-enhanced computed tomography (CT). In fact, this case illustrates very well that units that emphasize the functional aspect of epilepsy need to take a close look at what they are doing, because this approach is leading to a great deal of unnecessary and expensive investigation and may also occasion unnecessary surgical procedures. The implications are all too obvious. I would urge epilepsy units to place their emphasis on structural imaging first and foremost and to reserve functional tests for last resort. This approach saves a great deal of time, costly investigation, and, more important, morbidity.

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