Increase in epilepsy surgery in medically refractory epilepsy?
This article is authored by Dr. Sharad Rajamani, Consultant - Neurosurgery, Manipal Hospital Whitefield. Epilepsy is a disorder of overload of electrical activity in the brain, causing a large variety of different ways it can manifest.
This article is authored by Dr. Sharad Rajamani, Consultant – Neurosurgery, Manipal Hospital Whitefield.
Epilepsy is a disorder of overload of electrical activity in the brain, causing a large variety of different ways it can manifest. It can be caused by several different diseases, including lack of oxygen at childbirth, infections, strokes, abnormally formed brain, bleeding in the brain, injuries, or even tumours. The mainstay of the treatment of epilepsy is the use of medications and control is achieved in most cases. There is a small subset of patients who would not respond to the medicines or have severe side effects, and continue to have fits. These patients are the ones which might benefit from surgical intervention and removal of the focus where epilepsy starts or isolating the electrical storm preventing spread.
Different Forms of Epilepsy:
Epilepsy can present in different forms. Some are partial which causes seizures or jerky movements of one part or side of the body. Other forms of epilepsy can be sensory, causing hallucinations of one of the senses – smell, hearing, taste, touch, or sight. In this case, the individual does not lose consciousness as a rule of thumb.
Any patient with epilepsy has to undergo an Electroencephalogram (EEG) and Magnetic resonance imaging (MRI) scan to evaluate the source of epilepsy. Once a diagnosis of epilepsy is made, treatment is started depending on the type, nature, and intensity of epilepsy. The treatment depends on a number of factors and changing trends. Over the past decade, newer drugs, more targeted therapy, and surgical options have expanded, and are now fine-tuned to a great extent.
Surgical Intervention for Epilepsy:
Most cases of epilepsy are treated medically but a small subset of them will end up not responding to medical treatment and are called Refractory Epilepsy. Surgery for epilepsy might be an option for certain patients. Surgery for epilepsy can grossly be divided into the removal of the origin, blocking the extension of an electrical storm, and modifying signals.
However, an epilepsy surgery needs careful evaluation and identification of the focus, type of fits, and the way to address and treat them. It should also consider whether this patient will benefit from the surgical intervention. This entails the use of a complete EEG, localization of the site or source of abnormal electrical activity, and sleep deprivation Video EEG. Special MRI sequences and Glucose uptake studies help localize the lesion. In addition, a Neuropsychological evaluation, with IQ assessments, and evaluation of the side of the dominance of the brain.
Surgery is considered for patients after proper evaluation and counseling.
Many of the cases of focal disorders of the brain and certain special cases like temporal sclerosis (fibrosis) are prime candidates for early surgery as the earlier the focus is removed, the better it is for the patient in outcomes. In earlier times, surgery was offered only if there was an extreme failure of medications, usually after a long duration. This concept is now changing towards a more aggressive surgical removal of the source of the seizures, as it has been found that the longer the focus remains, the more it recruits, and the points of origin become more and more complex.
The target of epilepsy surgery has always been the aggressive treatment for foci of fits, and this ends up with medication-free lifestyles or decreased medications to minimal medicines. This is because some medications affect lifestyle and can cause reactions and cognition to some effect. Surgery can decrease these medicines and reduce their side effects. Early surgery can reduce or eliminate fits in up to 90% at the end of 5 years, and up to 75% at 10 years which definitely improves a patient’s quality of life.
This is the reason why early and more aggressive surgery for epilepsy has caught the eye of the neurosciences fraternity. Also, early and better detection techniques with more precise localization have brought about better results with surgery.