Language dominant, insular-opercular epilepsies are challenging to manage due complex seizure presentations and proximity to language cortex and associated white matter tracts. Most centres elected for extensive invasive stereo-electroencephalogram recordings and ablative procedures. We demonstrated in our retrospective cohort of 11 patients that focal resections can be undertaken safely and effectively using neuroimaging of seizures, lesions, language fMRI and high order tractography reconstructions based on a multi-fibre white matter modelling technique, and careful microsurgical techniques. This avoids risks associated with invasive procedures. Surgery performed under direct vision is more precise, likely safer, allows tailoring with intraoperative electrocorticography, and provides histopathology.
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