
Sahyadri Hospital, Pune, is a leading institution for treating epilepsy, especially refractory epilepsy in adults and children. Treating refractory epilepsy requires a team of medical experts and technicians across various disciplines. Sahyadri has a very well-coordinated team, one of the city’s most experienced teams of physicians, surgeons, and technicians. Sahyadri is the only hospital in Pune that offers complicated paediatric epilepsy surgery.
This article discusses what makes epilepsy surgery a very effective treatment option in certain circumstances. Let’s have a bird’ s-eye view of the different types of epilepsy surgery.
When Surgery Is Considered A Promising Treatment?
Epilepsy is a condition that afflicts approximately one in every 200 persons in India. There are different types of epilepsy, and not everybody with epilepsy needs surgery. Most cases of epilepsy respond to epilepsy medication (AEDs, i.e. antiepileptic drugs). Only 15 to 20% of cases amongst children and about 30% of cases in adults do not respond to treatment by medication. They are categorised as cases of refractory epilepsy. Refractory means stubborn. These stubborn epilepsy cases are considered for surgical treatment.
So, do all cases of refractory epilepsy benefit from surgery? The answer once again is ‘no’. In the early days of epilepsy surgery, doctors were forced to take a shot in the dark while deciding on surgery. Some operations succeeded, some failed. However, we can reasonably predict the success percentage with the fantastic developments in diagnostic technology over the years.
In a comprehensive classification, there are two types of epilepsy seizures. They are:
- Primary generalised seizure
2. Partial seizure.
Epilepsy results from abnormal electrical activity in the brain. When this abnormal electrical activity originates in the entire brain simultaneously, it is a generalised seizure. If the abnormal activity originates in just one part of the brain, it is a partial seizure. In a partial seizure, the abnormal activity can spread from one part to a larger brain area.
Surgery is not a preferred treatment option in a generalised seizure. It is a good treatment option for certain types of partial seizures.
How Do Doctors Select The Proper Case?
Doctors must select suitable cases for epilepsy surgery to ensure a fair degree of success after surgery. Choosing the right patient for epilepsy requires pre-surgical evaluation from a team consisting of a neurologist, radiologist, neuropsychologist, electrophysiologist, and neurosurgeon.
A patient has to undergo several diagnostic tests and thorough physical observation before doctors can recommend surgery for refractory epilepsy.
Focus On The Focus
The diagnostic tests for epilepsy are all directed towards identifying the part of the brain where the abnormal electrical activity starts. This is called the focus of the seizure. The focus can either be in the eloquent area, i.e. These brain areas are not responsible for crucial functions like motor movement, memory, speech, etc., or in the non-eloquent area, i.e., areas that control essential brain functions. Surgery is considered only if it can be done without affecting the crucial functions.
Structural abnormalities of the brain can often be responsible for epilepsy seizures. Seizures resulting from structural abnormalities have a structural focus on the seizure. The functional focus of a seizure is defined by the functions that get disrupted during the seizure. Surgery is usually successful if the structural and functional focus is the same.
If we mention that surgery is successful if the structural and functional focuses are the same, we will need to briefly explain the meaning of structural focus and functional focus. I don’t know if the above description is correct. Please replace it with whatever is proper.
Doctors identify the type of seizure and examine the frequency and extent of damage a patient suffers. When seizures are frequent, and damage is considerable, a surgical option must be considered.
Tests Required For Epilepsy Surgery
Doctors perform a battery of tests to determine whether surgery is a good treatment option in a particular case. These tests determine the focus of the epileptic seizure and whether surgery can achieve good results without affecting vital brain functions.
Doctors will recommend the following tests before deciding on epilepsy surgery.
MRI
An MRI is used to obtain a detailed image of the brain’s structure. A 3T MRI scanner is usually preferred for this test, as it can show even minute details of the brain’s structure. An MRI helps doctors identify abnormalities in the brain in great detail and determine the structural focus.
VIDEO EEG RECORDING
An EEG or Electroencephalogram records brain waves through electrodes placed on the scalp. The EEG can thus record any abnormal brain activity. For Video EEG recording, the patient is connected to an EEG machine and observed for 24 to 72 hours. The patient’s movements are recorded through a video camera. The actual seizure is captured on the video, and its time (time of occurrence/timing?) is linked to the EEG changes in the recorder. This helps to understand the electoral focus.
PET SCAN
During a seizure, the seizure focus records hypermetabolism, i.e., too much activity. Consequently, that part records hypometabolism (reduced activity) after the seizure. It is not feasible to do a test during the seizure. Hence, doctors look for areas of hypometabolism. A PET Scan can help doctors locate areas of hypometabolism. These areas suggest areas of seizure activity.
NEUROPSYCOLOGICAL TEST:
Doctors study the possible neuropsychological impact the surgery may have on the patient. Neuropsychological tests identify the functional loss or preservation of functions pre-surgically. It is vital that critical brain functions such as memory, speech, hearing, sight, etc., should not be adversely affected by the surgery. Understanding the pre-surgical functional loss also helps to identify the focus.
When all three – MRI, EEG and PET Scan indicate a result in favour of surgery, and the neuropsychological test gives a green signal, the chances of good recovery after surgery are close to 95%. If the results are mixed, doctors may recommend further investigations. Reports from all investigations may then strengthen or weaken the case for surgery
Types Of Epilepsy Surgery
There are two types of epilepsy surgery:
- Resective surgery
2. Disconnection surgery
In a resective surgery, the legion (affected part, i.e. the focus) is resected (surgically removed). A resective surgery can be curative.
Disconnection surgery disrupts the pathway of seizures, thereby reducing their spread in the brain. It is usually palliative in nature. Disconnection surgery can reduce seizures but does not eliminate them. However, it does aim to significantly reduce seizures while preserving as much brain function as possible.
Respective Surgery
Temporal Lobe Epilepsy Surgery
The cerebrum of the brain is divided into four lobes. The temporal lobe, seen in the figure, is located on either side of the brain, just above the ears. This lobe controls hearing, language, and memory. The most common type of epilepsy in teens and adults is focused in the temporal lobe.
In a temporal lobe resection surgery, the seizure focus in the temporal lobe is resected or cut away. While doing so, the surgeon has to ensure that the vital functions of hearing, language, and memory are not affected. The temporal lobe’s anterior (front) and mesial (deep middle) portions are usually the focus areas of epilepsy seizures. The prognosis (possibility of success) of a temporal lobe surgery is very high, especially so in mesial temporal sclerosis.
Extratemporal Resections
Other brain areas, such as the frontal, parietal, or occipital, are also resected depending on the focus region. However, these surgeries are more complicated, as preservation of functions is paramount. Disconnection Surgeries.
Disconnection Surgeries
Functional Hemispherectomy
An epilepsy condition called Rasmussen’s encephalitis is a type of epilepsy seen in children, though it can continue into adulthood for some. Those affected severely by this condition experience cognitive decline (decline in the ability to understand), loss of speech and partial vision loss, as well as paralysis of one side. Epileptic seizures are a significant part of this condition. The seizures involve continuous twitching or jerking of one side, called epilepsia partialis continua. (Epilepsia partialis continua is the continuous focal jerking of a body part, usually localised to a distal limb (hand/feet), occurring over hours, days or even years—Rasmussen’s Encephalitis results from inflammation (swelling) in one hemisphere of the brain. As you know, the brain has two hemispheres, the left and the right.
Rassmussen’s encephalitis affects one of them. If the damage from this condition is very severe and doctors fear that the damage will be permanent, a surgery called functional hemispherectomy is recommended. In this procedure, the cortex (the brain’s outer layer of neural tissue) is disconnected from all sub-cortical (inside) structures, and the interhemispheric commissures (tracts that connect the hemispheres) are divided. This disconnects the rest of the brain from the affected part, relieving the patient from seizures.
Functional hemispherectomy can also be advised for other types of epilepsy where an entire hemisphere is affected.
Multiple Subpial Transection (MST)
Cortical dysplasia results from enlarged neurons due to a congenital abnormality. Such malformation is commonly found near the cortex (the brain’s outer layer). Multiple Subpial Transection (MTS) is a surgical treatment advised for cortical dysplasia. MST is also advised if partial seizures originate in the eloquent areas of the brain (areas which are responsible for vital brain functions). This procedure makes shallow cuts (transections) into the brain’s cortex. These cuts interrupt the fibres connecting different parts of the brain. The method has proved to be successful in controlling seizures without causing any long-lasting impairment to vital functions. Language function, though, can, at times, get mildly disrupted.
Corpos Colostomy
The corpus callosum is a band of nerve fibres connecting the brain’s two halves (hemispheres). A corpus callosotomy interrupts the spread of seizures from hemisphere to hemisphere.
Corpos Collosotomy is advised as a palliative surgery for children who suffer from severe drop attacks; these attacks can often reach a figure of twenty to thirty attacks in a day. Children exhibiting retarded behaviour and a severe lack of focus on account of seizures can also benefit from this surgery. Seizures do not stop entirely after this procedure. They continue on the side of the brain in which they originate. However, the seizures become less severe, as they cannot spread to the other side.
Who Will Not Benefit From Surgery?
Not all cases of refractory epilepsy can benefit from surgery. Cases with refractory epilepsy secondary to (as a consequence of) a degenerative brain disorder or those with progressive myoclonic epilepsy (a rare epilepsy syndrome caused by a variety of genetic disorders) will not benefit from epilepsy surgery.
To sum up, epilepsy surgery is a treatment option when other options fail to relieve epileptic seizures. Surgery can be curative or soothing, depending on the kind of epilepsy afflicting a patient. Deciding on a surgery involves specialised investigations. Sahyadri Hospital is well-equipped with a competent and experienced team and state-of-the-art facilities for epilepsy surgery.
Why Sahyadri For Epilepsy Surgery?
Epilepsy is a result of disruption in the electrical activity of the brain, leading to seizures. Epilepsy surgery is a part of neurosurgery. Sahyadri Hospital is a leading hospital in the State of Maharashtra for treating neurological problems.
The hospital has a competent and experienced team for epilepsy treatment, including epilepsy surgery. We are the only hospital in Pune to offer complicated paediatric epilepsy surgery. The hospital has state-of-the-art machines for brain surgery and for all diagnostic testing needed for epilepsy surgery, which is done in-house. In the past year, 16 epilepsy surgeries were done at Sahyadri, four of which were very complex.
The Sahyadri Team For Epilepsy Surgery
Neurosurgeons
- Dr. Charudutt Apte
- Dr. Ranjit Deshmukh
- Dr. Manish Sabnis
- Dr. Nilesh Kurwale
Pediatric Neurologist
- Dr Sandeep Patil
- Dr. Deepa Divekar
Neuro Radiologists
- Dr Vardhan Joshi
- Dr. Anand Rahalkar
Neuro Psychologists
- Dr. Radhika Bapat
- Dr. Gauri Choudhary
- Dr. Poorva Dixit
Electro-Physiologists
- Dr. Varsha Wayse
- Ms. Hema Sowale
FAQs
- What is epilepsy surgery?
- Epilepsy surgery aims to remove or alter brain tissue, causing seizures when medications are ineffective.
- Who is a candidate for epilepsy surgery?
- Candidates are typically those with drug-resistant epilepsy or localised seizure activity in one brain area.
- What types of epilepsy surgery are available?
- Types include resective surgery, laser ablation, and neuromodulation, depending on seizure location and severity.
- How successful is epilepsy surgery?
- Success rates vary, but many patients experience a significant reduction in seizures or become seizure-free.
- Are there risks associated with epilepsy surgery?
- Risks can include infection, memory or speech changes, depending on the brain area treated, and other neurological effects.
Have queries or concern ?
About Author
Dr. Deepa Divekar
Contact: +91 88888 22222
Email – ask@sahyadrihospitals.com
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