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The 1999 William G. Lennox Lecture of the American Epilepsy Society : Advances in Neuroimaging : Surgical Localization

2001; Wiley; Volume: 42; Issue: 1 Linguagem: Inglês

1528-1167

Danica Gregory,

Fetal and Pediatric Neurological Disorders

In 1859, 24-year-old John Hughlings Jackson arrived in London on the completion of his medical training (2–4). Shortly thereafter, in 1862, he joined the staff at the National Hospital for the Paralyzed and Epileptic in Queen Square (2,3). The National Hospital was founded in 1857, and the reputations of the world-renowned institution and the brilliant Jackson would soon become inseparable (3). During his illustrious careers he introduced the basic concept of the partial or localizationrelated epilepsies (1–4). Previously, it had been assumed that epilepsy was only associated with generalized tonicclonic seizure activity of lower brainstem origin (1,2,4). Jackson established the relationship between the localization of a structural intra-axial abnormality in the cerebral cortex and the epileptogenic zone, i.e., the site of ictal onset and initial seizure propagation (1–4). He also characterized the partial seizure types, documented the importance of the aura, introduced the concept of the “discharging lesion,” and validated the effect of epileptic brain tissue localization on ictal behavior (1–4). Jackson emphasized the importance of identifying the “local lesion,” which represented the functional or structural abnormality associated with the “partial external symptoms” (1,2). The neurological history and examination at that time were the only diagnostic tools available to search for the offending “local lesion” (1,2). Confirmation of the underlying pathology required a postmortem examination. Surgical treatment was introduced as a potential therapy for partial epilepsy in 1886 at Queen Square (5,6). Victor Horsley performed the first cortical resection on a patient of Jackson’s who had a partial seizure disorder related to a remote head injury (5,6). A 22-year-old patient had been involved in a carriage accident that resulted in a skull fracture and frontal lobe encephalomalacia (5). The patient ultimately experienced a significant reduction in seizure tendency after surgical treatment. Horsley reported the favorable experience with surgery in three patients with partial seizures (5,6). The effectiveness of these initial operative procedures validated the basic hypotheses of Jackson concerning localization-related seizure disorders and demonstrated the importance of lesion-directed surgery in the treatment of partial epilepsy associated with a pathological substrate. The observations of Jackson provided the rationale for the innovations in the neuroimaging of epilepsy that would occur during the twentieth century.