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Epilepsy surgery involves a neurosurgical procedure where an area of the brain involved in seizures is either resected, disconnected or stimulated. The goal is to eliminate seizures or significantly reduce seizure burden. Approximately 60% of all people with epilepsy (0.4% of the population of industrialized countries) have focal epilepsy syndromes. In 15 to 20% of these patients, the condition is not adequately controlled with anticonvulsive drugs. Such patients are potential candidates for surgical epilepsy treatment.
First line therapy for epilepsy involves treatment with anticonvulsive drugs, also called antiepileptic drugs. Most patients will respond to one or two different medication trials. The goal of this treatment is the elimination of seizures, since uncontrolled seizures carry significant risks, including injury and sudden death. However, in up to one third of patients with epilepsy, medications alone will be unable to eliminate seizures, or cause unacceptable adverse effects. In these patients, work up for the feasibility of epilepsy surgery is considered.
Generally, surgery is considered in patients whose seizures cannot be controlled by adequate trials of two different medications. Epilepsy surgery has been performed for more than a century, but its use dramatically increased in the 1980s and '90s, reflecting its efficacy in selected patients.
The evaluation for epilepsy surgery is designed to locate the "epileptic focus" (the location of the epileptic abnormality) and to determine if resective surgery will affect normal brain function. Physicians will also confirm the diagnosis of epilepsy to make sure that spells arise from epilepsy (as opposed to non-epileptic seizures). The evaluation typically includes neurological examination, routine EEG, Long-term video-EEG monitoring, neuropsychological evaluation, and neuroimaging such as MRI, Single photon emission computed tomography (SPECT), positron emission tomography (PET). Some epilepsy centers use intracarotid sodium amobarbital test (Wada test), functional MRI or Magnetoencephalography (MEG) as supplementary tests.
Certain lesions require Long-term video-EEG monitoring with the use of intracranial electrodes if noninvasive testing was inadequate to identify the epileptic focus or distinguish the surgical target from normal brain tissue and function.Brain mapping by the technique of cortical electrical stimulation or Electrocorticography are other procedures used in the process of invasive testing in some patients.
Hemispherectomy involves removal or a functional disconnection of most or all of one half of the cerebrum. It is reserved for people with the most catastrophic epilepsies, such as those due to Rasmussen syndrome. If the surgery is performed on very young patients (2–5 years old), the remaining hemisphere may acquire some rudimentary motor control of the ipsilateral body; in older patients, paralysis results on the side of the body opposite to the part of the brain that was removed. Because of these and other side-effects, it is usually reserved for patients having exhausted other treatment options.
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