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N Engl J Med. 2017 Oct 26;377(17):1648-1656. doi: 10.1056/NEJMoa1703784.

Histopathological Findings in Brain Tissue Obtained during Epilepsy Surgery.

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From the Departments of Neuropathology (I.B., G.H., R.C., K.K.) and Neurosurgery (K.R.) and the Epilepsy Center (H. Hamer, H.S.), University Hospital Erlangen, Erlangen, the Epilepsy Center Bethel, Krankenhaus Mara, Bielefeld (C.G.B., M.P.), the Departments of Epileptology (C.E., G.W.) and Neuropathology (A.B.), University of Bonn Medical Center, and Medical Faculty, University of Bonn (J.S.), Bonn, the Neuropediatric Clinic, Epilepsy Center for Children and Adolescents, Schön Klinik Vogtareuth, Vogtareuth (T.P., H. Holthausen, M.K., P.A.W.), the Epilepsy Center Berlin-Brandenburg, Berlin (H.J.M.), the Epilepsy Center (G.H., A.S.-B.) and Department of Neurosurgery (J.Z., D.H.H.), University Hospital, and the Department of Neuroradiology, Medical Center-University of Freiburg, and Faculty of Medicine, University of Freiburg (H.U.) Freiburg, Kork Epilepsy Center, Kehl-Kork (B.J.S., T.B.), the Departments of Neuropathology (S.V.) and Neurology (U.R.), University Hospital Greifswald, Greifswald, the Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen (H.L., Y.W.), the Department of Neurology, University of Ulm, Ulm (H.L., Y.W.), the Epilepsy Center, Department of Neurology, Ludwig-Maximilians-University Hospital, Munich (S.N., E.H., P.A.W.), Sächsisches Epilepsiezentrum Radeberg, Radeberg (T.M., M.L.), Epilepsy Center Frankfurt Rhine-Main and the Department of Neurology, Goethe University, Frankfurt am Main (F.R., A.H.), the Epilepsy Center Hessen-Marburg, Philipps-University Marburg, Marburg (F.R., A.H.), and the Department of Social Medicine, Occupational and Environmental Dermatology, Heidelberg University, Heidelberg (T.L.D.) - all in Germany; the Clinical Epileptology and Experimental Neurophysiology Unit (R.S.) and the Department of Neurophysiology, Epilepsy Center (G.A.), IRCCS Foundation, Neurological Institute C. Besta, and the Claudio Munari Epilepsy Surgery Center, Niguarda Hospital (L.T., G.L.R.), Milan, and the Pediatric Neurology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence (R.G., C.B.) - all in Italy; Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (K.P.B., F.L.), and the Department of (Neuro)Pathology (E.A.), University Medical Center Utrecht, Utrecht, the Department of Neurosurgery, VU University Medical Center (J.C.B.), and the Department of (Neuro)Pathology, Academic Medisch Centrum, University of Amsterdam (E.A., A.M.), and the Department of (Neuro)Pathology, VU University Medical Center (E.A., A.M.), Amsterdam, Stichting Epilepsie Instellingen Nederland, Heemstede (E.A.), and the Department of Neurosurgery, Academic Center for Epileptology, Maastricht University Medical Center, Maastricht (O.S.) - all in the Netherlands; the Department of Neurosurgery, Sainte-Anne Hospital, and Paris Descartes University, Paris (F.C.), the Department of Neurology, Michallon Hospital, GIN INSERM Unité 836, Grenoble Alpes University, Grenoble (P. Kahane), and the Department of Clinical Epileptology, Sleep Disorders and Functional Neurology in Children, University Hospitals of Lyon, and the Brain Dynamics and Cognition team, Lyon Neurosciences Research Center, Lyon (A.A., A.U.-C.) - all in France; the Departments of Neuropathology (M.T.) and Clinical and Experimental Epilepsy (M.C.W., S.M.S., J.S.D., A.W.M.), UCL Institute of Neurology, and the Developmental Biology and Cancer Programme (T.S.J.) and Developmental Neurosciences Program (J.H.C.), UCL-Great Ormond Street Institute of Child Health, and the Department of Histopathology, Great Ormond Street Hospital for Children (T.S.J.), London, and Young Epilepsy, Lingfield (J.H.C.) - all in the United Kingdom; the Departments of Neurology (C.Ö.) and Pathology (B.O.), Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; the Department of Pediatric Neurology, Motol Epilepsy Center, Charles University in Prague, and the 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic (P. Krsek); the Department of Anatomical Pathology, Hospital Pedro Hispano, Matosinhos (M.H.), and the Laboratory of Neuropathology, Department of Neurosciences, Hospital de Santa Maria-Centro Hospitalar de Lisboa Norte, Lisbon (J.P.) - both in Portugal; the Epilepsy Unit, Child Neurology Department, Hospital San Juan de Dios, Barcelona (A.A., A.U.-C.); the Department of Pediatrics, Medical University Vienna, Vienna (M.F., A.M.), the Departments of Neurology (E.T.) and Neurosurgery (P.A.W.), Christian Doppler Medical Center, Paracelsus Medical University, Center for Cognitive Neuroscience, Salzburg, and the Department of Neurology I, Neuromed Campus, Kepler Universitätsklinikum, Linz (T.J.O.) - all in Austria; the Swiss Epilepsy Center and Department of Neurology, University Hospital, Zurich, Switzerland (T.G.); the Department of Neurology, Hospital Ruber Internacional, Madrid (A.G.-N., R.T.D.); and the Neurosurgical Department (B.Z.) and Epilepsy Monitoring Unit (K.G.), St. Luke's Hospital, Thessaloniki, Greece.



Detailed neuropathological information on the structural brain lesions underlying seizures is valuable for understanding drug-resistant focal epilepsy.


We report the diagnoses made on the basis of resected brain specimens from 9523 patients who underwent epilepsy surgery for drug-resistant seizures in 36 centers from 12 European countries over 25 years. Histopathological diagnoses were determined through examination of the specimens in local hospitals (41%) or at the German Neuropathology Reference Center for Epilepsy Surgery (59%).


The onset of seizures occurred before 18 years of age in 75.9% of patients overall, and 72.5% of the patients underwent surgery as adults. The mean duration of epilepsy before surgical resection was 20.1 years among adults and 5.3 years among children. The temporal lobe was involved in 71.9% of operations. There were 36 histopathological diagnoses in seven major disease categories. The most common categories were hippocampal sclerosis, found in 36.4% of the patients (88.7% of cases were in adults), tumors (mainly ganglioglioma) in 23.6%, and malformations of cortical development in 19.8% (focal cortical dysplasia was the most common type, 52.7% of cases of which were in children). No histopathological diagnosis could be established for 7.7% of the patients.


In patients with drug-resistant focal epilepsy requiring surgery, hippocampal sclerosis was the most common histopathological diagnosis among adults, and focal cortical dysplasia was the most common diagnosis among children. Tumors were the second most common lesion in both groups. (Funded by the European Union and others.).

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