Epilepsy surgery is a surgical intervention which is designed to remove an area of the brain where seizures are found to originate. This surgery is found to work best for people who are having seizures which originate from the same place in brain. For a person to be considered for epilepsy surgery, the patient must have tried at least two anti-seizure drugs without any success. In case two most appropriate drugs are found to have failed, it is extremely unlikely that other anti-epileptic drugs would be able to help the patient.
Why Undergo Epilepsy Surgery?
Epilepsy in most cases can be reduced & sometimes it is also possible to eliminate seizure activity. However, repeated epileptic seizures can cause the following.
- Drowning, when seizures occur during swimming or bathing
- Broken bones & other injuries from falling during seizures
- Damage to brain due to prolonged seizures
- Sudden death is a rare complication of epilepsy
Type of epilepsy surgery which a patient requires depends upon the type of seizures they experience & where they originate in the brain. These generally include the following.
One of the most common types of epilepsy surgeries is removal of a portion of brain & which is usually about the size of a golf ball which is causing seizures. This type of surgery is known as resective surgery where a lobe can be removed, or a portion of lobe or a lesion. This surgery most often is highly successful.
This is another type of epilepsy surgery which is known as corpus callosotomy. It severs network of neural connections between left & the right halves (hemispheres) of brain. This type of surgical intervention is primarily used in children who are having severe seizures starting in one hemisphere & spreading to the other side. This surgery can effectively help reduce the severity of seizures.
This is the most radical type of epilepsy surgery which removes the outer layer of half the brain. Known as hemispherectomy, this procedure is used for children who are having seizures due to damage to just one hemisphere of the brain. These types of problems are found to occur in few rare cases & are usually present at birth or appear in early infancy. However, chances of full recovery are best among younger children.
One of the tests which are sometimes used for diagnosing epilepsy is brain scan. Patients may either undergo CT (computerized tomography) scan or MRI (magnetic resonance imaging) scans for this purpose. Though both these procedures use different technology, they produce images of brain which can show specific causes for epilepsy. Commonly known causes for epilepsy include malformations of brain development (problems in formation of brain), scarring on brain, damage to brain from injuries to head, or following infections like meningitis. Whenever a specific cause is found, it is known as epileptogenic lesion & which can also be different in each person.
When a patient is referred for epileptic surgery, he will probably have to go to a specialist center for tests. There are several different pre-surgery tests which are required before they are given a go-ahead for epilepsy surgery. These include EEG (electroencephalogram), MRI scans, & video telemetry which are an EEG that is also being filmed. Then there are other types of scans which may also be performed that trace a chemical which is injected into the body. This procedure will show detailed information about where exactly seizures originate in brain. Psychological & memory tests are also used to see as to how lifestyle & memory may be affected following epilepsy surgery. These types of tests also help neurosurgeons see as to how the patient is likely to cope-up with the impact epilepsy surgery can make. These tests are generally meant to confirm the following.
- Deciding whether neurosurgeons can reach the epileptogenic lesion through surgery so as to safely remove affected portion of brain without causing additional problems.
- Ensure as to which other parts of the brain may get affected by epilepsy surgery, like for example parts which control sight, speech, hearing or movement.
- To make sure that the patient is having good chances of having epileptic seizures stopped by the procedure.
- To find out if the patient is having any other medical conditions which would stop them for undergoing surgery for epilepsy.
Results from these tests will help the patient & neurosurgeons decide as to whether epilepsy surgery is a good option & as to what results can be safely expected from epilepsy surgery. However, for some people, results may show that epilepsy surgery is not a good option since a majority of patients recommended for epilepsy surgery & having undergone these tests are unable to undergo this surgical procedure. Neurosurgeons will talk with patients about possible risks & benefits of epilepsy surgery based upon the results of these pre-surgery tests.
Undergoing any type of surgery on brain is a big decision & the patient may have plenty of questions or concerns which they would like to discuss before they can make up their mind. Neurosurgeons are quite used to this fact because it is an important decision before beginning to prepare for surgery. Neurosurgeons will explain to patients about potential risks of undergoing surgery for epilepsy in order to give the patient the big picture about undergoing epilepsy surgery. Although neurosurgeons can give advice & information to patients, the final decision always rests with the patient. Quite often, patients are also offered some type of pre-surgical counseling in order to give patients time about how they feel about having to undergo surgery for epilepsy.
When a patient is a good candidate for epilepsy surgery, their pre-surgical evaluation includes the following.
- EEG Baseline Electroencephalogram – This is a test involving placing electrodes on the scalp so as to measure electrical activity which is produced by brain.
- Video EEG – This is a continuous EEG with video monitoring that record seizures as they occur. For this test, patients are required to be admitted to hospital since seizure medications have to be either reduced or temporarily stopped in order to induce occurrence of seizures. Correlating changes in EEG with body movement during seizure helps in pinpointing the area of brain where these seizures are starting.
- CT or MRI scans of Head – CT & MRI scans can effectively identify structural problems like scar tissue or lesions in brain which could be causing seizures.
- PET Positron Emission Tomography & Functional MRI – Functional MRI & PET scans can monitor brain’s activity & detect abnormalities as well.
- SPECT Single-Photon Emission Computerized Tomography – Scanned images can vary in color depending upon the amount of blood which is flowing to different areas of brain. Flow of blood is typically higher in portions of brain where epileptic seizures originate. Moreover, in some cases, neurosurgeons combine many types of imaging techniques which can be helpful in locating troublesome areas of the brain.
In order to avoid infection, hair of the patient will be clipped short over the section of the skull which will be removed during the operation. Quite often, the operational team will shave the area in such a way that other parts of the hair will be able to cover up the bald patch following surgery. However, some patients would like the entire head to be shaved. Moreover, shaving is generally not done for child patients.
- Patients will have a small flexible tube intravenously placed & their blood pressure, heart rate & oxygen levels monitored throughout the surgical intervention. There will also be an EEG monitor which will be recording brain waves during surgery so as to better localize the portion of the brain where seizures begin.
- Epilepsy surgery is generally performed under influence of general anesthesia. This means that the patient will be unconscious during the operational procedure which involves making and opening in the skull in order to access the brain. Moreover, in rare circumstances, the neurosurgeon may even awaken the patient during part of surgery to help the operating team determine as to which part of the brain controls movement & language.
- The window which was created for surgery is finally replaced & fastened to the remaining skull for healing following the procedure. Most epilepsy surgeries take at least four hours of time to complete.
Patients will be kept in a special recovery area where they will be carefully monitored as they awaken from anesthesia following surgery. They may also need to spend the first night in an intensive care unit following surgery. Total hospital stay following epilepsy surgery for most patients is usually between three to four days.
- When epilepsy surgery patients awaken, their heads will be painful & swollen. Most patients require narcotics for pain relief for at least the first few days following surgery. An ice pack on the head can also be helpful. Most postoperative pain & swelling will resolve within many weeks though.
- Epilepsy surgery patients will not be able to return to school or work for at least one to three months following operation. They should also relax & rest the first few weeks following surgery & then gradually escalate their activities.
- It is unlikely that patients will need intensive rehabilitation after epilepsy surgery as long as the operation was completed without any complications like loss of speech, paralysis or stroke.
Risks & complications following epilepsy surgery may vary depending upon which type of epilepsy surgery was used & the portion of the brain which was involved.
- Memory Problems – Temporal lobe generally handles language & memory functions. Just in case surgery was performed on this part of the brain can cause difficulties with speech, understanding or remembering.
- Behavioral Changes – Epilepsy surgery performed to the frontal lobe can affect behavior including attention or concentration, motivation as well as mood changes, depression & impulse control.
- Double Vision – Double vision can sometimes develop after temporal lobe epilepsy surgery. Problems with vision can also occur with occipital lobe epilepsy surgery.
- Reduced Visual Field – Sometimes, epilepsy surgery can also result in reduced field of vision.
Most often, outcomes of epilepsy surgery depend upon underlying causes. For example, some seizures can resist medications but they are most likely to benefit from epilepsy surgery. Nearly 90 percent of patients experiencing temporal lobe seizures witness significant reduction or even cessation of seizures following epilepsy surgery. However, patients must continue to take anti-seizure medications even after epilepsy surgery in order to help improve chances of remaining free of seizures. Moreover, doctors can wean patients away from anti-seizure drugs after a year or two. Patients should nevertheless review with doctors about recovery & seizure activity following epilepsy surgery. As to how often this would be required must be decided between the patient & the neurosurgeon.
Operating team would have talked with the patient about aims of epilepsy surgery prior to the operation including how successful they expect surgery to be. Successful surgery for some people means completely stopping seizures, while for others it could mean reducing severity or number of seizures. However, it takes about two years of time following surgery in order to fully measure success of epilepsy surgery. Almost 70 percent of the people, which means 7 in 10, undergoing temporal lobe surgery find that the operation is able to stop seizures & they are able to become seizure-free; For the other 20 percent, which means 1 in every five, seizures generally reduce both in intensity, & number of episodes. Around 50 percent of the people, which is about half, undergoing temporal lobe surgery are found to be seizure-free even after 10 years following surgery, but most of these patients were still taking AEDs for some time. Epilepsy surgery patients can talk to neurosurgeons about which may be the most appropriate time to begin slowly coming off AEDs.
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