Specialty Program

Epilepsy Surgery

Patients who come to Epilepsy America for epilepsy surgery can expect to have a team working with them from the first consultation appointment, through testing and decision-making phases, the surgery itself and in the post-surgical follow up phase.

Why would a patient be sent for epilepsy surgery?
When a patient has not achieved adequate seizure control through medications or other conservative treatments, epilepsy surgery may be considered as a treatment option. This can be the case in around 30% of patients with epilepsy. It is important to have this discussion early in the course of treatment; this should occur as soon as it is noted that medications are not being effective in seizure control.

What are the objectives of epilepsy surgery?
Epilepsy surgery has several objectives, including improved seizure control, enhanced quality of life, and reducing the impact of epilepsy and seizure medications on daily functioning.

How does the medical team decide that epilepsy surgery is a good option for the patient?
The decision to undergo epilepsy surgery is only made after a comprehensive evaluation by a specialized medical team, including neurologists specializing in epilepsy (epileptologists), neurosurgeons, neuropsychologists, and other healthcare professionals has been completed. The goal of the evaluation is to determine where the seizures are coming from and to assess whether it is safe to remove the part of the brain that has been identified as the source of the seizures making sure no important brain function is lost (e.g., movement or speech).
To determine the seizure location and to carefully tailor the surgical intervention, a detailed assessment of the individual’s medical history, seizure frequency and characteristics is performed through seizure monitoring (video-EEG monitoring), brain imaging studies (such as MRI, SPECT and PET) other EEG modalities as Magnetoencephalography (MEG), neuropsychological testing, and various other tests. On some occasions when the seizure focus cannot be determined with these tests, a more invasive evaluation may be needed with electrodes placed on the brain (subdural electrodes) or in the brain (depth electrodes).
To ensure that the patient will not experience a deficit if that part of the brain is removed, some other set of test need to be performed. These could include neuropsychological evaluation, Wada Test, functional MRI, MEG and brain stimulation (brain mapping).

Is there more than one option for epilepsy surgery?
There are several surgical procedures available for epilepsy, depending on the specific needs and characteristics of each patient.
There are two main surgical categories: 1) Removal or modification of brain tissue through surgery and 2) neuromodulation which uses technology/devices to act directly upon nerves stimulating them and producing a response. 3) There is a third technique called laser ablation (LITT) which will be briefly discussed below.

1) Surgical removal or modification of brain tissue is used to reduce or eliminate seizure activity. Some neurosurgical interventions include lobectomies which involve the removal of a brain lobe (e.g., frontal lobe), lesionectomies which involve removing a lesion (e.g., tumor or vascular malformation) that is causing focal seizures, hemispherectomies (removal of one hemisphere) and disconnection surgeries which involve disconnecting the bundle of nerves connecting the two brain hemispheres (i.e., corpus callosotomy)

a) The first (removal or modification of brain tissue through surgery) is the most common type of epilepsy surgery and involves removing the brain tissue that has been identified as the source of epileptic activity. The goal is to remove the epileptic focus while minimizing damage to healthy brain tissue. This procedure is typically used for focal epilepsy (epilepsy in which seizures originate from a specific, pinpointed area of the brain).
b) Lesionectomies involve the removal of a lesion that causes the seizures, commonly an area of brain that has been scarred, or that has a vascular malformation or a tumor.
c) Hemispherectomies involve the removal of one brain hemisphere. This surgery is done mostly in children with conditions that affect one hemisphere such as Rassmussen’s encephalitis.
d) Disconnection surgeries involve a procedure in which the bundle of nerves connecting the two hemispheres of the brain, known as the corpus callosum, are partially or completely cut. This surgery is mostly utilized for individuals who have severe forms of epilepsy, such as Lennox-Gastaut syndrome, where seizures involve both hemispheres and cause significant disability.

2) Neuromodulation involves the implantation of a technological device that modulates (changes) neurological activity with the purpose of controlling seizures; An example of neuromodulation is the responsive neuro-stimulator (RNS), a device that is implanted in the brain and when it detects abnormal electrical activity, delivers targeted electrical stimulation to prevent seizures. This procedure is suitable for individuals with focal epilepsy who have not achieved seizure control through other treatments or individuals in which the seizure focus overlaps with an important brain function. Another example is the vagus nerve stimulator (VNS), a device that is implanted in the chest to stimulate a major nerve called the vagus nerve. This nerve is involved in regulating brain activity. The device delivers electrical impulses to the brain to help control seizures. Lastly, deep brain stimulation (DBS) involves a surgical procedure in which an electrode is implanted deep in the brain (basal ganglia) to modulate brain activity thereby controlling seizures.

3) And lastly, there are also other surgical options, that do not involve neuro stimulation or conventional brain surgery; these use a technique called laser ablation (LITT). This technique is utilized to remove tumors or other small lesions that are causing epileptic seizures. In this procedure, surgeons make a small incision in the skull to insert a laser probe into the target area. They then use controlled heat to destroy the tissue where the seizures are originating.

In summary, epilepsy surgery offers many important and innovative options for epilepsy treatment. However, brain surgery is complex and requires very careful planning, precise localization of the epileptic focus and brain functions (brain mapping) and collaboration between various medical disciplines. The surgical team weighs several factors in deciding to proceed with surgery, including the individual’s seizure type, seizure frequency, location of the epileptic focus, potential risks and benefits of surgery, and the impact it might have on the individual’s quality of life. Following epilepsy surgery, a comprehensive post-operative care plan is developed to monitor the individual’s recovery and optimize seizure control. Close follow-up appointments with the medical team, including neurologists and neurosurgeons, are necessary to evaluate the effectiveness of the surgery and make any necessary adjustments to medication or other treatments. Epilepsy surgery can offer significant benefits for eligible patients, including reduced seizure frequency, improved seizure control, and enhanced quality of life. However, it is important to note that not all individuals with epilepsy are suitable candidates for surgery, and the decision to proceed with this type of intervention should be made in close consultation with the medical team, the patient and the family.

Here is what to expect if someone is going to have epilepsy surgery
Before the surgery
The patient’s hair is cut or shaved over the part of the skull that will be removed by the surgeon. An intravenous (IV) line will be placed in a vein in the patient’s arm or hand to deliver anesthesia, IV fluids, and any other medicines that may be needed during the surgery.
During the surgery
The surgical team monitors the patient’s heart rate, blood pressure and oxygen levels during the surgery and at times, an EEG monitor may be used to record the patient’s brain waves during the operation. This is so the medical team can be even more certain about which is the part of the brain from where the seizures originate. That is the part of the brain that the surgeon will need to remove. The surgeon will typically remove a small portion of the skull to gain entry to the brain.
Although usually, patients undergoing epilepsy surgery are completely anesthetized, (they are unconscious) during the operation, at times, the surgeon may awaken the patient briefly. This happens when the surgeon needs to make sure which parts of the patient’s brain control language or movement (to ensure these are not affected). No pain is felt because medication is used to control for that.
After surgery, the part of the skull that was removed at the beginning is put back, fastened and wrapped.
After the surgery
Like with most surgeries, the patient is moved to a special recovery area where they are monitored for when they wake up from the anesthesia. Usually, the patient is placed in the intensive care unit (ICU) after surgery. The patient may expect to be hospitalized after this surgery for about three or four days.
When the anesthesia wears off, the site of the surgery will be swollen and some pain will be felt. This is treated with pain medication for a few days and an ice pack can be used too. Given time to rest and recover, this will get better in a few weeks.
The patient should be prepared to remain out of work or school for a few months; that is the time that is needed to best recover from this type of surgery. The surgeon will guide the patient and family on how and when to begin to participate in physical activities and when to resume pre-surgical routines.

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