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

2. 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

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

4. 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

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

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

7. EEG Slide
/ROUTINE 7

8. 8

9. Brain MRI

10. MRI 10

11. MRI

12. SPECT SCAN 12

13. PET SCAN 13

14. 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

15. 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

16. Subdural Electrodes

17. 17

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

19. 19

20. 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

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

22. 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

23. 23

24. 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.

25. Deep Brain Stimulation (DBS)25

26. Neuropace 26

27. 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. -

28. 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”

29. Thank you