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Epilepsy surgery is appropriate for certain patients with medically refractory seizures. To be considered, a patient should have the following characteristics:
Epilepsy surgery is a highly individualized procedure. The details of the seizure type and seizure focus must be defined as precisely as possible before surgery. most patients will undergo numerous tests and procedures as part of the presurgical workup. The following steps and tests are standard procedure at UC San Diego Health System and at most comprehensive epilepsy centers in the U.S.:
The test is named for the physician who developed it, Dr. Juhn Wada. The purpose is to test each side of the brain for language and memory. The neurologist will identify the side of the brain responsible for language and confirm that the side opposite the seizure focus (side that will no be operated on) can support memory.
The procedure is performed by a specially trained radiologist, working with the epilepsy team. A sterile catheter is inserted into the femoral artery, near the groin area. The catheter is guided through the artery, past the heart, into the carotid artery on one side of the neck. An angiogram is then performed, using a special liquid dye to take pictures of the blood vessels of the brain on that side. Next, a small amount of short-acting anesthesia is injected into that side of the brain. Within seconds, the opposite side of the body may become temporarily weak and numb, indicating that the anesthesia is working and it is time to test language and memory. The neuropsychologist will then ask the patient a series of questions. After a few minutes, when the anesthesia has worn off, the weakness and numbness will go away. The neuropsychologist will then ask some follow-up questions. The same procedure is then repeated on the other side of the brain.
The interventional radiologist will explain the Wada test in detail before the procedure. Informed consent is required, as with all invasive procedures. Most patients remain in the recovery area under observation for six hours after the procedure.
Patients with a seizure focus in the language dominant side of the brain (usually the left side) may undergo intraoperative language testing. This is done to be as sure as possible that language areas are not damaged during the surgery. In such cases, the anesthesiologist will wake the patient after the brain surface is exposed.
The epilepsy team will then test different parts of the surface of the brain for evidence of language function. You may be asked to count, talk or name items in pictures while the surgeon tests for areas of language function. The procedure is not painful, since the brain itself does not have pain receptors.
Local anesthesia is used throughout the procedure. After language areas are identified, the patient is put back to sleep with general anesthesia for the rest of the procedure.
The Epilepsy Center Team has had very good outcomes for epilepsy surgery, comparable to the best centers in the world. Of all patients who have temporal lobe epilepsy surgery, 75 percent are seizure-free after surgery and usually continue on medication. Another 20 percent are significantly better, but not seizure-free. The remaining 5 percent experience no significant improvement. The results for surgeries outside the temporal lobe are less satisfactory, with 38 percent becoming seizure-free, 50 percent experience improvements and 12 percent see no improvement. Certain features may improve or reduce the chances of success for a particular patient. Your doctor can better explain the circumstances of your case.
It must be noted that the odds are never 100 percent, and there is no guarantee that seizures will go into remission.
Most patients leave the hospital within one week, many within 3 - 5 days of surgery. Most recuperate at home for several weeks, gradually easing back into their school, work or home activities over the next few months. You may need more or less time depending on your general health.
You will meet with the neurosurgeon that will perform the procedure, to have your individual questions answered.
There is always a small risk of a major complication, including complications involving anesthesia, intraoperative bleeding, stroke or even death. This is true of any operation in the brain. Epilepsy surgery is a carefully planned procedure, carried out under optimal circumstances to remove the region of brain causing the seizures, and to spare parts of the brain necessary for everyday functions.
After surgery there may be swelling and even bruising around the eye on the side wher the surgery was done. The eye may be puffy for up to several weeks. Some patients do not raise their eyebrow perfectly on the side of the face where the surgery was. Some have jaw pain or limited jaw movement. Headaches are common, but should not be severe. Some patients complain of a sense of fullness in the ear or earache. These problems tend to resolve in a matter of weeks or months.
The contours of the skull are usually smooth, but they may not be perfect after surgery. Surgeons make every effort to place the scar behind the hairline, when possible.
After temporal lobe surgery, some patients may have a small “blind spot” in their upper visual field, which is seldom noticeable to the patient. This is also called a visual field cut. The reason for the blind spot is that nerve fibers travel from the back of the eye to the back of the brain, passing through part of the temporal lobe. To understand the blind spot, imagine staring forward at the center of a huge clock. With the eyes fixed, it may be difficult to see details in the upper portion of the clock - for example, from around 10 to 12 o’clock or 12 to 2 o’ clock. Shifting the position of the eyes or head will change the position of the blind spot, so most people are unable to detect this on their own.
Neuropsychological testing before and after surgery shows very satisfying results. Most people experience no change in overall IQ. Patients having left-sided surgery are more likely to show a small drop in verbal memory or naming, balanced against some improvement in other test scores. Rarely, for reasons that are not well understood, a patient will experience a greater than expected decline in memory, or behavioral or emotional problems after temporal lobe surgery. The presurgical neuropsychologic and psychiatric testing and Wada tests are very important in screening for patients that might have behavioral or memory problems after surgery.
Occasionally, a patient will experience disappointment after surgery. At the UC San Diego Epilepsy Center, as well as nationally, it is recognized that epilepsy surgery is an imperfect science. Every effort is made to select only those patients who stand a very good chance of improvement, and for whom the benefits appear to outweigh the risks of surgery. We do not wish to portray epilepsy surgery as a routine procedure or “cure.” Every case is unique and is evaluated with a great deal of care and consideration – not by one physician – but by the entire epilepsy team. You should proceed with epilepsy surgery only after you have discussed the matter carefully with your physician and family, and have had all of your questions answered.
Yes. We recommend continuing the medication for at least two years even if you are completely seizure-free before attempting to wean off them completely. During this time, your doctor may work with you to lower the dose or change the number or types of medications you take. If you continue to have auras on medication, your doctor may advise against weaning yourself completely off the medication.
Driving privileges are granted by the DMV, not the doctor. We advise patients to wait until they are seizure-free for six months before applying for driving privileges. Patients who have never driven or patients who have not driven for many years, are advised to begin with a driver training course and proceed slowly. Your doctor will assist with the medical information required on the California DMV forms. Patients who live outside of California should follow the rules of their local DMV.
Once it is clear that a patient has refractory epilepsy, there is little to gain by waiting. After decades of uncontrolled seizures, a patient may develop a lifestyle of restricted activity and feel unprepared to take advantage of new opportunities, even if he or she becomes seizure-free after surgery. Thus, age, attitudes, lifestyle, family support and educational background all enter into the equation. The average age at the time of surgery is 20 - 40 years. The ideal age may be younger still. However, age itself is not a reason for exclusion from surgery. Patients less than one year of age and patients 60 and older have been operated on successfully.
If you wish to meet with a person who has already had epilepsy surgery, this can be arranged. Be sure to ask questions and remember that communication with your doctors is essential.
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