E Feoli MD North East Regional Epilepsy Group 2012 Epilepsy Surgery E Feoli MD North East Regional Epilepsy Group 2012

Comprehensive Epilepsy Center Referrals Controlled Not Controlled Evaluation: ●History/Exam ●EEG ●Imaging Controlled Not Controlled Video-EEG Epilepsy Non-epileptic Events Refer Medical Management Surgical Management 2

The Poorly Controlled, Intractable Seizure Patient Despite medical management, patient continues to have frequent, debilitating seizures Commonly on polytherapy (more than one medication) 3

Candidates for Epilepsy Surgery Persistent seizures after initial attempts at treatment (at least 2 appropriate AEDs at reasonable doses) Impaired quality of life due to ongoing seizures For focal resection: single seizure focus that can be safely removed Palliative procedures: corpus callosotomy, subpial transections, VNS, others

Epilepsy Surgery To determine where the seizures are coming from Video-EEG monitoring MRI MRS: PET: SPECT: 5

Goals of Video-EEG Monitoring Epilepsy vs. non-epileptic events Characterize epilepsy type Pre-surgical evaluation FOCAL EPILEPSY 6

EEG Slide 99-10-31/ROUTINE 7

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Brain MRI

MRI 10

MRI

SPECT SCAN 12

PET SCAN 13

Epilepsy Surgery To make sure that it is safe Wada test: to study speech and memory Neuropsychological testing: mental functions (IQ, memory, attention) and personality assessment Psychological evaluation Ophthalmologic evaluation 14

Epilepsy Surgery Some cases in which the localization is not clear or where function could be affected will require INVASIVE ELECTRODES Depth electrodes Subdural electrodes 15

Subdural Electrodes

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Types of Epilepsy Surgery Temporal Lobectomy Extratemporal Resections Hemispherectomy Corpus Callosotomy 18

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Outcome after epilepsy surgery Anterior temporal lobectomy 70-80% seizure free Neocortical resection With lesion: 50-80% seizure free Without lesion: 30-50% seizure free Hemispherectomy Significant improvement Corpus Callosotomy Significant improvement for drop attacks 20

Complications of surgery Low rate of complications Infections Bleeding Anesthesia Function 21

Vagus Nerve Stimulator (1997) Intractable epilepsy patient without focus or desires interim step before epilepsy surgery Goal is to reduce amount/severity of seizures vs. cure Device surgically implanted in left chest/axilla area Coils around left vagus nerve Stimulation is automatic; patient can additionally stimulate device if aura 22

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VNS Therapy VNS: <10% seizure free, 30-50% with at least 50% seizure decrease, more with lesser improvement; effects on seizure severity? Vagus nerve stimulation (VNS) is delivered through a pacemaker-like pulse generator surgically implanted into a subcutaneous pocket in the left chest area below the left clavicle. Since FDA approval in July 1997, the VNS Therapy pulse generator system has been implanted in more than 20,000 patients worldwide. Stimulation parameters are set through a telemetric wand that is held over the area of the implanted pulse generator and controlled through special software programmed by the treating physician. Electrical pulses reach the brain via the left vagus nerve, where the lead is attached. Through programming, stimulation can be adjusted for each patient. Furthermore, patients can acutely control stimulation and side effects via a hand-held magnet.

Deep Brain Stimulation (DBS) 25

Neuropace 26

Conclusion -Not all patients with refractory epilepsy are surgical candidates. -Patients with FOCAL refractory epilepsy are candidates for surgery. -Multiple steps are required before your doctor concludes that you are a surgical candidate. -

Conclusion You might be a good surgical candidate however a RESECTIVE procedure might not be possible, due to the proximity o the seizure focus to “eloquent cortex”

Thank you