Brain, Vol. 124, No. 6, 1253-1254,
June 2001
© 2001 Oxford University Press
Book reviews |
Intractable Focal Epilepsy.
By John Oxbury, Charles Polkey and Michael Duchowny. 2000. Sidcup: Harcourt Publishers. Price £125. Pp. 878. ISBN 0-70202-428-7
Department of Neurology, Atkinson Morleys Hospital, London, UK
There is a steadily increasing number of textbooks within the field of clinical epilepsy, with authors and editors pursuing a variety of themes with variable emphases, from the focused and concise to the almost overwhelmingly comprehensive. To justify their existence, new works need to have a special theme or direction. This volume selects the field of focal intractable epilepsy and strongly emphasizes a surgical approach.
The text is presented as a single volume, a moderately heavy one at nearly 900 pages. The three editors come from three distinct centres, two in the UK and one in the USA, freeing the book of any special bias; all are long-established and will need no introduction even to neurologists with only a passing interest in epilepsy. The editors have selected 80 co-authors (approximately a quarter are North American) and again, most names are very familiar, with a few welcome newcomers.
On initially opening the book, an obvious strength is that layout on the page is particularly clear and easy on the eye, with a useful, never patronizing, summary box at the end of each chapter. The vast majority of chapters are well referenced, with most references being before 1998. High-quality illustrations are used extensively, with a few in colour. The text is divided into five very unequal sections: 242 pages on seizure semeiology and the aetiology of epilepsy syndromes; 178 pages on investigations in the patient with intractable focal epilepsy; 80 pages on medical management; 286 pages on surgical treatment and outcome; and a final 24 pages on the health economics of intractable epilepsy and epilepsy surgery.
It is easy to regard the book as simply two sections: first, a very comprehensive introduction to focal intractable epilepsy as a clinical problem and, secondly, a thorough account of epilepsy surgery in this setting. It is this emphasis that sets Intractable Focal Epilepsy apart from other current competitors.
The editors set out their purpose with clarity in the introduction. The title is deceptively simple—we all know exactly what this book will be about—but defining the words `intractable' and`focal' is not easy. `Intractable' is defined operationally as two years failed treatment with adequate doses of three of the five leading antiepileptic drugs (AEDs) in adults, though this definition is felt to be too strict for some children. The word `focal' has become a little passé in epilepsy circles, but here is championed for its simplicity. The stated aim of the book is to present a clinical account of intractable focal epilepsy for neurologists, neurosurgeons, neurophysiologists, neuroradiologists and other professions in contact with epilepsy, particularly those wishing to enter the field. A timely emphasis is placed on the fact that, although epilepsy surgery requires an exacting and detailed approach, it could be undertaken in many neuroscience centres not currently involved in epilepsy surgery. The editors also observe that remediable substrates of apparently intractable epilepsy may go unrecognized and hope that this book will reduce the likelihood of such a misfortune.
Inevitably, this volume has some of the faults of a very large authorship—some repetition of material, inconsistency of terminology and a small degree of inconsistency of opinion. Also, again almost unavoidably, a few authors emphasize material from their own unpublished case series at the expense of a more thorough review of the published literature. Chapters are also variable in their accessibility to a relatively uninformed reader; some, such as Chapter 2 (Diagnosis and classification) and Chapter 35 (Drug treatment in adults) take a comprehensive approach starting at a basic level; others such as Chapter 11 (Mesial temporal lobe epilepsy syndrome with hippocampal and amygdala sclerosis) include advanced material from the basic sciences and comprehensive descriptions of seizure semeiology, with no easy way in for the newcomer. For other readers, however, these more challenging chapters will be particularly interesting—a work such as this cannot expect to be pleasing to all readers from all disciplines throughout.
The first section of the book (semeiology of focal seizures and underlying causes), following excellent short reviews of epidemiology and mortality data, proceeds logically through a series of chapters describing clinical features of seizures according to anatomical onset and a further set of chapters describes each potential aetiology. A surprisingly short chapter on the semieology of temporal lobe seizures is included for completeness, though the material is covered again much more thoroughly later in the book. A chapter on parietal seizures is more satisfying and Chapter 8, on occipital seizures, is one of the highlights of the book. A brief but important chapter provides a welcome and useful account of seizures of multilobar onset. A further highlight of the book is a comprehensive account of malformations of cortical development in Chapter 10. An appropriately long chapter describing the syndrome of temporal lobe epilepsy with hippocampal and amygdala sclerosis is followed by a series of short and well-written chapters covering focal epilepsy due to vascular disorders, trauma, tumours, infections, neurocutaneous disorders, Rasmussen's syndrome (another highlight) and specific childhood syndromes including (perhaps controversially in a book on focal epilepsy) West syndrome. All of these are clear, concise and useful.
The second section describes approaches to investigation, including imaging, neurophysiology and a comprehensive account of neuropsychometry, psychiatric evaluation and quality of life measurements. On first pass the authors appear to have omitted an adequate description of hippocampal sclerosis (HS) from Chapter 24 (Radiological investigation), but further reading reveals this comes much later in the very extensive Chapter 44 in the fourth section of the book, on surgical treatment. This clearly avoids repetition, but the contents of Chapter 44 might perhaps more logically be placed in section two. The editors' defence is that detailed evaluation of HS is often only a part of the later stages of surgical work-up, not part of preliminary evaluation. Chapter 24 (Radiological investigation) covers other aetiologies briefly but accurately. Subsequent chapters on PET and SPECT (25 and 26) and later descriptions of their role in surgical evaluation cover the ground but fail to grapple with the thorny issue of whether such imaging has been superseded by the rapid advances in MRI; the clinical role of these techniques remains uncertain. The chapter on SPECT emphasizes the importance of visual inspection of images, but was written before the maturation of newer coregistration and subtraction techniques which point to a clear role of a computer-driven automated approach in certain settings. Three chapters on EEG and MEG are excellent and extremely clear, though again slightly confusingly, invasive monitoring of children is discussed here but invasive monitoring in general is discussed in section four (on surgery). Equally direct, clear and educational are the chapters on psychometry, psychiatric evaluation and quality of life issues.
Section three comprises a brief series of chapters on medical treatment, covering drugs, diet, psychological approaches and medical treatment outcomes. We are told in the introduction not to expect this section to be comprehensive, and indeed it is not, presenting brief descriptions of most, but not all, currently available AEDs. Since discussion of undoubtedly effective treatment (e.g. levetiracetam) is omitted or very limited, it is perhaps surprising to find space given to biofeedback and psychotherapy. The coverage of drug treatment is, however, balanced, careful and clear.
Section four is a much more comprehensive and lengthy series of chapters covering all aspects of surgical treatment of epilepsy: patient selection, `work-up', operative strategies, anaesthesia for epilepsy surgery, surgical complications and outcome. Having held back important chapters on temporal lobe imaging and invasive EEG recording to this part of the book, section four could easily stand alone as a highly readable volume devoted to epilepsy surgery. Most of the strongest chapters of the book are here. Particularly helpful are the chapters on MRI of the temporal lobe and on invasive neurophysiological evaluation, rightly emphasizing the role of MRI as the crucial tool for detecting HS, and the place of invasive monitoring as a carefully executed test of prior hypotheses. No new epilepsy surgery programme should seriously consider itself competent without the approaches outlined here. Hippocampal volumetry and signal change detection are carefully described. A clear emphasis is made that invasive monitoring should never be required in more than a minority of patients and should never be used as a desperate last resort. Two further chapters on psychometry and carotid amobarbital testing are also particularly helpful, comprehensive and a pleasure to read. A short chapter describes the, as yet immature, field of preoperative functional imaging and points towards some imminent exciting developments. This is followed by a concise and didactic chapter outlining the recommended approach to tailoring the sequence of investigations to each presurgical patient. Six chapters describe surgical techniques in detail, including temporal lobe resections, extratemporal cortical resections, hemispherectomy, functional surgery, brain stimulation and anaesthetic techniques for epilepsy surgery. The extent and authority of these chapters is the greatest strength of the book, the only criticism possible being the lack of illustrations—surgeons (to whom these chapters are surely directed) will not need pictures, but physicians (struggling to imagine the anatomy) would benefit. Indeed, a good set of line drawings of surgical approaches would be of great utility for explaining the procedures to many members of the multidisciplinary team, and even to patients. The concluding chapters of this section describe outcome data, including unusually useful accounts of surgical complications and psychological sequelae.
A brief nod to the importance of economic considerations is included as the final section five.
The editors set out their aims very clearly—have they been achieved? Certainly an overview of focal epilepsy, particularly the approach to surgery, has been kept to a single volume without sacrificing important detail; the material is overwhelmingly clinical rather than describing basic science; a newcomer to this clinical area will gain a broad and substantial knowledge within a secure framework; and those working in established epilepsy programmes will find much of interest. Furthermore, a number of chapters can be tackled from different perspectives and from a wide variation in levels of prior knowledge, making the book accessible and useful for many members of a multidisciplinary epilepsy team. Undoubtedly, those reading the book to pursue the possibility of developing an epilepsy surgery programme will find their enthusiasm fired and the vital features of the process clearly signposted. Any neurology department with ambitions to develop a wider ranging epilepsy service, many established epilepsy departments and every neurologist or neurosurgeon contemplating developing an epilepsy surgery service, should place a copy of this book within reach of the whole team.
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