Epilepsy Surgery
E Feoli MD
North East Regional Epilepsy Group
2012
Comprehensive
Epilepsy
Center
Referrals
Evaluation:
●History/Exam
●EEG
●Imaging
Controlled
Not Controlled
Video-EEG
Non-epileptic
Events
Refer
Epilepsy
Medical
Management
Surgical
Management
The Poorly Controlled, Intractable
Seizure Patient


Despite medical management, patient
continues to have frequent, debilitating
seizures
Commonly on polytherapy (more than one
medication)
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:
Goals of Video-EEG Monitoring

Epilepsy vs. nonepileptic events

Characterize epilepsy
type
Pre-surgical evaluation
FOCAL EPILEPSY

EEG Slide
Fp1-F7
F7-FT9
FT9-T7
T7-P7
P7-O1
Fp2-F8
F8-FT0
FT0-T8
T8-P8
P8-O2
FT9-FT0
A1-A2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
ECG-RF
ECG-RF
SaO2(%) 0
0
0
0
0
HR(bpm)
0
0
0
0
Comment
0
spike
0
0
99-10-31/ROUTINE
0
0
0
0
0
0
0
0
Fp1-F7
F7-FT9
FT9-T7
T7-P7
P7-O1
Fp2-F8
F8-FT0
FT0-T8
T8-P8
P8-O2
FT9-FT0
A1-A2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
ECG-RF
SaO2(%) 0
0
0
0
0
0
0
0
0
0
HR(bpm)
0
0
0
0
0
0
0
0
0
Comment
0
Brain MRI
MRI
MRI
SPECT SCAN
PET SCAN
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
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

Subdural Electrodes
Types of Epilepsy Surgery




Temporal Lobectomy
Extratemporal
Resections
Hemispherectomy
Corpus Callosotomy
Outcome after epilepsy surgery

Anterior temporal lobectomy


Neocortical resection



With lesion: 50-80% seizure free
Without lesion: 30-50% seizure free
Hemispherectomy


70-80% seizure free
Significant improvement
Corpus Callosotomy

Significant improvement for drop attacks
Complications of surgery

Low rate of
complications




Infections
Bleeding
Anesthesia
Function
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
VNS Therapy

VNS: <10% seizure free,

30-50% with at least 50% seizure decrease,
more with lesser improvement; effects on
seizure severity?
Deep Brain Stimulation (DBS)

Neuropace

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