What is Epilepsy Surgery?
Epilepsy is a chronic (long-term) neurological (brain, spinal cord, and nerves) disorder, where recurrent, unprovoked seizures occur due to abnormal electrical activity inside the brain. Most patients suffering from epilepsy usually achieve good results with anti-epileptic medicines. But in patients where anti-epileptic medicines do not provide relief, for those patients, epilepsy surgery becomes very important and often a life-changing treatment option. It aims to either remove or disconnect the area of the brain that leads to seizures, or modify the brain activity to decrease the frequency at which seizures occur, and how serious they are.
The main target of epilepsy surgery is to achieve long-term relief from significant seizures when medicines fail. Beyond controlling seizures, epilepsy surgery also aims to improve the patient’s overall quality of life by reducing the physical, emotional, and social impact of uncontrolled epilepsy. Successful epilepsy surgery can help the patient regain independence, increase cognitive performance, and decrease the risks that are associated with repeated seizures, especially injuries, and sudden unexpected death in epilepsy (SUDEP).
Types of Epilepsy Treatments
The surgery options for epilepsy range from techniques that remove or disconnect brain tissue to implant devices that help regulate the electrical activity. Thus, epilepsy surgeries are of a broad category that offers a complete cure, and palliative, whose objective is to reduce the frequency of seizures and their intensity. Types of epilepsy surgery are:
1) Resective and Ablative Surgeries
- Focal resection is the removal of a small part of the brain where the seizures usually begin. These are again of two types, that is, Temporal lobectomy, where brain tissue is removed from the temporal lobe of the brain. This is one of the most successful epilepsy surgery types in adults. Lesionectomy is a surgery that is performed if the seizure focus is a specific well well-defined abnormal structure, like a tumor, blood vessel malformation, or scar tissue. The surgeon removes the lesion, after which there is almost complete control of seizures.
- Laser interstitial thermal therapy (LITT) is a minimally invasive procedure that uses a laser probe to destroy the brain tissue that causes seizures with pinpoint accuracy.
- Hemispherectomy is a rare procedure that is performed on children with severe epilepsy, where seizures involve a complete hemisphere of the brain. These are again of two types: Functional hemispherectomy, which involves disconnecting the affected hemisphere from the rest of the brain rather than removing the complete tissue. Anatomical hemispherectomy is where one complete hemisphere of brain tissue is removed.
2) Disconnection surgeries
These are procedures that interrupt nerve pathways to provide relief from seizures. These are used when brain tissue cannot be surgically removed.
- Corpus callostomy is where surgeons cut the corpus callosum, the main nerve fiber bundle connecting the two hemispheres of the brain. This stops seizures from spreading from one side of the brain to another and is often used for “drop attacks” resulting in a fall.
- Multiple subpial transection (MST) involves making a series of shallow cuts in the grey matter of the brain to interrupt the flow of seizure impulses. This is done for seizures that begin in eloquent areas of the brain that control speech and movement.
3) Neurostimulation Devices
These treatment methods use implanted electrical devices to help control seizures without removing or disconnecting the tissue.
- Vagus nerve stimulation (VNS) is a pacemaker-like device that is implanted in the chest and connected to the vagus nerve in the neck. The device then sends continuous electrical signals to the brain to help disrupt the seizure activity.
- Responsive neurostimulation (RNS) is a neurostimulator that is implanted in the skull with electrodes placed at the seizure focus. This device continuously monitors the brain and delivers a small electrical pulse to stop a seizure when it detects that activity.
- Deep-brain stimulators (DBS) are electrodes that are surgically implanted deep within the brain and connected to a device that is placed under the skin in the chest. It then sends electrical pulses to disrupt seizure-causing signals in adults.
| Procedure Name | Epilepsy Treatment |
|---|---|
| Type of Surgery | Major, medium invasive, and minimally invasive, depending on various subtypes |
| Type of Anesthesia | General anesthesia |
| Procedure Duration | 3-4 hours for major surgery, 45-90 minutes for minimally invasive surgery |
| Recovery Duration | Weeks to months, depending on procedure |
Epilepsy Treatment: Pre-Op & Post-Op Care
Epilepsy surgery requires sizeable preparation, specialized intra-operative care, and careful long-term post-operative management. The whole epilepsy procedure is managed by a multidisciplinary team to ensure the best possible outcome for patients who are resistant to drug treatment for epilepsy.
Before the epilepsy surgery procedure
The pre-operative stage of epilepsy surgery focuses on locating the area from which seizures are generated and determining if the removal of that area of the brain is safe. The evaluation and testing part involves examination of the medical history of the patient, followed by imaging tests of the brain done by using high-resolution magnetic resonance imaging (MRI), positron emission tomography (PET), and single-photon emission computed tomography (SPECT).
Post this video-electroencephalography (video-EEG) is done, where a patient is admitted to the hospital’s epilepsy monitoring unit. Medicines are reduced to provoke and record seizures with video and EEG, which helps in determining the exact location of the seizures. Neuropsychological testing is done to understand the patient’s cognitive functions.
If these non-invasive tests fail, the surgeon performs invasive tests where intracranial electrodes are placed in procedures like stereoelectroencephalography. This is placed directly on the brain’s surface to locate a seizure in an even more accurate manner. Patient is prepared by taking informed consent, managing medicines, and preparing the site of surgery.
Intra-operative Care – The Epilepsy Surgery
The Intra-operative care involves the surgery phase itself, with continuous monitoring by the patients to ensure the patient’s safety and overall a better outcome.
Anesthesiologists manage the patient’s status by making sure of a stable cerebral perfusion pressure and avoiding any increase in the intracranial pressure.
Total Intravenous Anesthesia (TIVA) is preferred over inhalational agents for procedures that involve neuromonitoring. Any reactions between medicines taken by the patient and anesthesia are also closely monitored.
Surgical techniques and monitoring involve electrocorticography (ECoG), where EEG electrodes are directly placed on the brain to record the activity and confirm the extent of tissue that can be removed.
Functional mapping involves testing the critical functions, like speech, motor, and sensory functions of the patient, briefly during the procedure through cortical stimulation.
Intraoperative neuromonitoring is done by using techniques like somatosensory evoked potentials (SSEP) and motor evoked potentials MEP) are used to continuously assess the integrity of neural pathways.
Awake craniotomy is a procedure that the surgeon performs while the patient is awake to make sure of continuous monitoring.
Seizures during the operation are managed by irrigating the surgical area with cold saline and administering anti-epileptic medicines.
After the Epilepsy Surgery
Post-operative care is very important after epilepsy surgery to prevent complications, promote healing, and ensure long-term well-being. It is a complete and multidisciplinary process that continues even after the patient leaves the hospital post-surgery.
The key aspects of post-operative care after any epilepsy surgery are to monitor for infections, bleeding, and any neurological deficits. Ongoing seizure activities and mood changes are also managed.
Healing is promoted by giving proper care to the patient, which involves wound management of wound with rest and minimal physical activity. Anti-epileptic medicines should be continued for the patient even after two years of surgery, before reducing the frequency. Post-operative treatment manages any relapse of seizures.
The patient needs extensive support to recover attention span, cognitive, and memory skills. If effective post-operative care is given, the patients can quickly regain their independence to lead a normal day-to-day life.
Benefits of Epilepsy Treatment at Yashoda Hospitals
- Significant seizure control
- Reduced medication
- Improved cognition
- Enhanced quality of life
- Reduced seizure frequency
- Improvement in mood and cognitive ability
- Fewer hospital visits
- Lower risk of injury
- Decreased mortality rates
- Better long-term results
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