Book Review

Intractable Focal Epilepsy

N Engl J Med 2001; 344:1873June 14, 2001

Article

Intractable Focal Epilepsy
Edited by John M. Oxbury, Charles E. Polkey, and Michael Duchowny. 878 pp., illustrated. Philadelphia, W.B. Saunders, 2000. $225. ISBN: 0-7020-2428-7

There is a vast difference between focal and generalized epilepsy, and even within these categories there are extensive differences in symptoms, causes, and treatments. Intractable Focal Epilepsy, the first book of its kind, deals with one major category of epilepsy in depth. It has been long awaited by epileptologists, since it deals with one of the greatest challenges in the field: the fact that most patients with medically intractable epilepsy have focal epilepsy.

The main objective of the editors was to review the field in one volume. They hoped to provide adequate information for the nonspecialist and to help specialists set up comprehensive epilepsy programs. The book largely achieves those goals.

After several introductory chapters, the first section of the book discusses nomenclature and causes. In addition to the common causes of focal epilepsy, such as mesial temporal sclerosis, cortical malformations, vascular disease, tumors, and infections, the book has insightful chapters on esoteric causes, particularly in children.

In the next three sections the book discusses diagnostic evaluation, medical management, and surgical treatment. The section on medical management is limited to an overview of treatment strategies and discusses only a few old and new antiepileptic drugs. The section on surgical treatment is much more comprehensive, describing in detail surgical options from curative procedures to palliative treatments. The book ends with a discussion of the economics of intractable epilepsy, addressing the cost and the benefits of aggressive surgical treatment.

The organization of the section on diagnostic studies, particularly the discussion of neuroimaging, is disappointing. There is no question that our ability to detect focal structural or metabolic abnormalities has changed therapeutic options tremendously. Unfortunately, the book presents neuroimaging in a confusing way. Initially, the authors discuss neuroimaging incompletely in the section on diagnostic evaluation, providing few details about current methods that may be helpful in patients with nonlesional neocortical disturbances. With respect to magnetic resonance imaging (MRI), there is no mention of T₂ relaxometry or spin–echo density in MRI sequences. The authors provide a brief description of fluid-attenuated inversion recovery and diffusion-weighted imaging, but no discussion of how these sequences are used in the evaluation of epilepsy. Ictal and interictal single-photon-emission computed tomography is mentioned only briefly, and functional MRI and magnetic resonance spectroscopy are conspicuously missing.

Discussions of some of these methods appear later in the book, in the section on the surgical workup, with emphasis on the evaluation of mesial temporal sclerosis. However, there is no discussion of the detection of extratemporal lesions, a diagnostic challenge for epileptologists. No doubt, an updated edition will be called for in the next few years, with the advent of gamma-knife surgery, deep-brain stimulation, and intrathecal drug delivery.

Teresa A. Tran, M.D.
MINCEP Epilepsy Care, Minneapolis, MN 55118