Who should consider epilepsy surgery, and when

Epilepsy surgery.
For the right patient, epilepsy surgery can be a very effective treatment option.

Epilepsy surgery has long been considered a treatment of “last resort.” And while these procedures are still usually not our first treatment option after an epilepsy diagnosis, advancements in the field have made brain surgery for epilepsy a safer, more effective, and, in some cases, less invasive treatment option than in the past.

Unfortunately, many people who qualify for surgery never get a surgical evaluation, or it’s delayed for years because of a patient’s hesitation about the procedure or because a doctor never recommended it. 

I know having surgery performed on your brain sounds scary. But epilepsy surgery can be a valuable treatment option for some people – even completely eliminating seizures, something no other epilepsy treatment can do right now. Don’t let fear keep you from learning about whether you might be a candidate for surgery and how we use new procedures to reduce risks and optimize outcomes.

Why not to wait to get a surgical evaluation

Seizures affect brain function such as memory as well as quality of life, and long-term uncontrolled seizures increase these risks along with the possibility that seizures may spread to involve more areas of the brain.

Research published in January 2017 illustrated the importance of not delaying a surgical evaluation. It showed that 58 percent of people who had surgery were seizure-free after five to 10 years, compared with 17 percent who did not have surgery. The author noted that the longer a person had epilepsy, the less likely he or she was to be seizure-free after surgery.

It’s not uncommon for us to see patients who have had poorly controlled epilepsy for 20 years or more. Every doctor has a different timetable for when he or she recommends a surgical evaluation, and there are still some who spend years having patients try multiple medications. It’s also possible that a medication may work for a time only to have the seizures return after a honeymoon period. This can occur over and over with new medications, and before you know it, years have passed and your epilepsy is still not well-controlled.

If you’ve had uncontrolled seizures for a year or more and your doctor has not recommended a surgical evaluation, request one. We want to assess you before the condition has had significant time to negatively impact your brain or quality of life. Request an appointment online.

Who is a candidate for epilepsy surgery?

I recommend you get a surgical evaluation if:

  • Seizures start in one area of the brain: Every patient’s seizures are unique. Through imaging and a review of your seizure history, we can tell if your seizures are coming from one specific area of the brain, a condition known as focal onset epilepsy. Surgery for this type of seizure has the highest rate of cure. Conversely, if the seizures come from multiple areas of the brain, or if the risk to brain function is too high, the surgical options may be more limited.
  • Medications aren’t working: You have tried two or three medications and your seizures are not well-controlled. Up to 40 percent of people with epilepsy fail to respond to antiepileptic medications. This is known as intractable epilepsy.

Research has shown that if the first couple medications a patient with epilepsy tries do not work, it’s increasingly unlikely that further drugs will be effective. A 2012 study found that 50 percent of trial participants were seizure-free after trying one drug, 13 percent after a second, and 4 percent after a third.

Safer, more effective epilepsy surgeries

Bradley Lega, M.D.
Bradley Lega, M.D.

Patients considering surgery to treat epilepsy often worry about possible side effects. These depend on the type of surgery  and where in the brain we are operating. You and your doctor will discuss the risk factors of your particular procedure.

No surgery, no matter where in the body, is without risk. But thanks to new imaging techniques and advanced surgical procedures, the risk of complications and side effects of epilepsy surgery is lower than it’s ever been.

Three major advancements have greatly improved our ability to successfully treat patients with epilepsy with surgery:

Stereoelectroencephalography (stereo EEG)

One of the biggest advancements we’ve made in epilepsy surgery is better pinpointing where a seizure is coming from. We are one of few centers in the U.S. to use a minimally invasive approach known as stereoelectroencephalography, or stereo EEG. This type of “brain mapping” allows us to operate on the exact area affected and avoid adjacent tissue that may control important functions such as speech.

With stereo EEG, we surgically place electrodes in the brain, which takes about four hours. We then monitor the electrodes in our Epilepsy Monitoring Unit for about a week to locate the source of the seizure before removing the electrodes, which usually takes less than 30 minutes.

We use the stereo EEG results to help determine if you’re a candidate for therapeutic surgery and, if you are, which type of procedure would work best. For example, I treated a patient who had been having uncontrolled seizures for 15 years but doctors had been unable to determine where the seizures were coming from. Thanks to stereo EEG, we were able to locate the source and remove that part of the brain, leaving her seizure-free.

Responsive neurostimulation

Neurostimulators prevent or disrupt seizures by sending pulses of electricity to the brain. This type of brain stimulation has been around for only about five years. We implant electrodes connected to a computer chip in the area of the brain that is causing seizures. It analyzes brain waves and delivers stimulation just as a seizure begins. Early trials showed seizure frequency reductions of 44 percent one year after the device was implanted, 53 percent after two years, and up to 66 percent after three years.

Laser interstitial thermal therapy

This is a type of laser ablation, a minimally invasive procedure in which we burn away targeted tissue in the affected area of the brain. We make a small incision in the scalp and guide a laser wire through a catheter to the brain tissue we want to burn away.

Compared to standard resection surgery, patients who have laser interstitial therapy recover faster and experience fewer side effects. This is because the procedure allows us to target an area of the brain more precisely while causing less harm to healthy tissue. Laser interstitial thermal therapy can reduce seizures or eliminate them entirely, although sometimes an individual patient’s seizures may be better treated with other types of therapy.

Questions to ask when considering epilepsy surgery

Whether to have epilepsy surgery is a decision you want to be confident in making. Ask your doctor these questions before making your decision:

  • What technology and procedures do you use? You want to find a facility with an experienced staff that routinely uses new tools, such as stereo EEG and responsive neurostimulation, and traditional techniques, such as temporal lobectomy.
  • Who will be on my care team? Epilepsy surgery is not a one-person job. You want a diverse team surrounding you throughout the process, including surgeons, radiologists, and neuropsychologists.
  • What outcome can I expect? Make sure you understand whether the recommended procedure is expected to leave you seizure-free or instead reduce the frequency and severity of seizures.
  • What are the potential side effects of this procedure? It’s important to carefully weigh the benefits of surgery against its risks. If the side effect profile of a procedure concerns you, ask if you’re a candidate for a less-invasive option. If the answer is no, consider getting a second opinion. You may get the same answer, but you’ll have covered your bases. 

The decision to have epilepsy surgery should not be taken lightly, but it’s an important and often effective option to consider – and sooner is better than later.

 

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