A New Perspective on Dual Pathology in Epilepsy

The approach to dual pathology in drug-resistant epilepsy is a challenging issue for clinicians. The main aim is to precisely determine and resect the epileptogenic focus, which is commonly complicated by the limitations of scalp-EEG monitoring, the restricted availability of intracranial EEG recording, the indecision to select between staged surgery and dual lesionectomy, and encountering with the possible postsurgical deficits. Previous studies with a focus on the management of dual pathology have certain limitations, such as the enrolment of mixed groups of patients, imprecise reports of EEG findings, a lack of control groups, short-term follow-ups, and limited reports of postsurgical neuropsychological evaluations and deficits. In this manuscript, I have suggested a classification that has mainly addressed dual pathologies containing hippocampal sclerosis —the most common dilemma for epileptologists — and I have tried to divide them in a practical way for both clinicians and researchers. Lesions other than hippocampal sclerosis have also been considered to show the essential need to revise the definition of dual pathology and to encourage researchers to approach them as a distinct and important category. Moreover, the classification has mentioned multiple pathologies and categorized them into commonly encountered subgroups. It seems that using this classification to categorize dual and multiple pathologies based on anatomical characteristics and findings of presurgical evaluation might be helpful to design more targeted studies on homogenous groups of patients and simplify uniform
planning.