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Abnormal cortical development and epilepsy: from basic to clinical science.Edited by Spreafico R, Avanzini G, Andermann F. (Pp 324, hardback; £39) London: John Libbey, 1999. ISBN 0 86916 579 5
In his chapter in this book entitled “Neuronal migration disorder and epilepsy in infancy”, Vigevano emphasises that brain malformations represent a causal factor in 3–4% of all epilepsies, although this percentage increases to 18–20% in drug resistant epilepsies. With every new generation of MRI scanner, more and more patients with epilepsy are recognised to have a cortical developmental abnormality, and the aetiological significance of these to the development of epilepsy has opened up exciting new fields in the understanding of the pathophysiology of epilepsy and its treatment. This book is a compilation of papers presented at a meeting on epileptogenic cortical developmental abnormalities, organised by the editors. As with books produced in this way there are strengths and weaknesses, with a bias towards specific topics of interest.
The book starts with a short introduction by Frederick Andermann, followed by several chapters on cortical development and animal models. These early chapters are not easy reading but persistence is rewarded by information of direct clinical relevance from the dry basic scientific details—for example, I learnt that work with animal models has shown that pathological changes continue for years after the initial insult, explaining the delay in the development of clinical epilepsy. Furthermore, the progressive maturation of the neurotransmitter pathways could explain why neonatal encephalopathies are often catastrophic, and why children can grow out of their epileptic tendency, even with lesional epilepsy.
The later chapters on electroclinical imaging, neuropathological studies, genetics, and surgery are more relevant for the clinician. In this section, several of the authors emphasise the error of using the term “neuronal migration disorders” for all dysplasias, when the disturbance can be of neuronal proliferation or organisation and not always an arrest of neuronal migration. Of particular interest to me were the chapters on neuroradiology of malformations, neuronal migration disorders and epilepsy in infancy, schizencephaly: clinical and genetic findings, and periventricular nodular heterotopia, especially the genetic implications of recognising these various malformations. I also enjoyed Guerrini's excellent chapter on the development of polymicrogyria. As in his other publications, he points out that polymicrogyria is the only cortical developmental abnormality which can produce ESES with eventual spontaneous remission, and when this pathology is identified on neuroimaging, surgery should be avoided. This leads us to the two chapters on the problems of resective surgery in focal developmental abnormalities and epilepsy; the first by the Montreal group and the second outlining the Italian/French experience. Both emphasise the specific difficulties of deciding the demarcation of surgical resection in these patients. I was particularly interested in the approach of Munariet al to two step surgery, reoperating with more invasive electrocorticography if the seizures do not stop with lesionectemy alone. While acknowledging that cortical dysplasias can be intrinsically epileptogenic, Munari et alstate that, in practice, the epileptogenic zone is often wider than the MRI limits of the lesion, suggesting either that the adjacent cortex is also epileptogenic or that microscopic pathology extends further than that seen on MRI images.
The book is a useful addition to the literature on cortical dysplasias. It does not aim to be a comprehensive review of the topic and the reader would need considerable prior knowledge of the subject to find the book useful.
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