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Different approaches to resective epilepsy surgery: standard and tailored.

Intra-operative approaches to resective surgery for medically intractable epilepsy, especially cases involving temporal lobes, vary from anatomically standardized operations to those tailored to the location of epileptogenic zones and eloquent areas in individual subjects. The choice of approaches seems to depend on different views of the variability in epileptogenic zones and eloquent areas and on the reliability of identifying these areas intraoperatively, including the value of interictal epileptic activity. Evidence relating to these issues is reviewed. Although the choice of an intra-operative approach has a major effect on the risks and costs of the evaluation for epilepsy surgery, with higher risks and costs for approaches using standard operations or extra-operative recording, no controlled study has compared the approaches. Indeed, the reported outcome for optimal candidates for each approach is nearly identical, providing little justification for use of approaches with higher risks and costs in all patients.