Surgical Treatment of Epilepsy

Epilepsy Awareness Day

Columbia Comprehensive Epilepsy Center Anil Mendiratta, M.D.

Definitions

Seizure

Epilepsy

Types of seizures

Partial

Generalized

Scope of the Problem

10% of the population will have a seizure in their lifetime 1% of the population suffers from epilepsy

3,000,000 4,000,000 people

in the US

Advances in the Management of Epilepsy

Medical Treatment Surgical Treatment Overall Approach

Advances: Overall Approach

No seizures

No side effects

Advances: Medical Treatment

Medications in use before 1993

Phenobarbital 1912 Phenytoin (Dilantin) 1938 Primidone (Mysoline) 1954 Ethosuximide (Zarontin) 1960 Carbamazepine (Tegretol) 1974 Valproate (Depakote) 1978

Advances: Medical Treatment

New Medications since 1993

Felbamate (Felbatol) 1993 Gabapentin (Neurontin) 1993 Lamotrigine (Lamictal) 1994 Topiramate (Topamax) 1996 Tiagabine (Gabitril) 1997 Levetiracetam (Keppra) 1999 Zonisamide (Zonegran) 2000 Oxcarbazepine (Trileptal) 2000 Pregabalin (Lyrica) 2005

Advances: Surgical Treatment

Comprehensive epilepsy centers Video-EEG monitoring MRI, PET, SPECT, MEG, fMRI

Who is a candidate?

Focal epilepsy Resistant to medication Disrupt quality of life

Epilepsy Surgery

Focal cortical resection Corpus callosotomy Hemispherectomy Multiple subpial transections Vagal Nerve Stimulation

Brain

Epilepsy Surgery: Objectives

Resect the epileptogenic focus Preserve neurological function

Epilepsy Surgery: Goals

Seizure Freedom Improved Quality of Life

Epilepsy Surgery: Outcomes

Structural Lesions (low grade tumors, vascular malformations)

up to 80 - 90% seizure free

Arteriovenous Malformation

Epilepsy Surgery: Outcomes

Mesial Temporal Sclerosis

up to 80% seizure free

MRI Right MTS

Epilepsy Surgery: Outcomes

Non-lesional or dysplasia

up to 50% seizure free

Surgical complications

5% complication rate 1-2% permanent

Surgical Evaluation

Video-EEG monitoring

Surgical Evaluation

Brain imaging - MRI, PET, SPECT

Surgical Evaluation

Neuropsychological Testing

Surgical Evaluation

Intracarotid Amobarbital (Wada) Test Functional MRI

Surgical Evaluation

+/- Intracranial Recording Cortical mapping

Surgical Evaluation

Multidisciplinary Case Conference

Case 1

50 y.o. man, occupational therapist, intractable epilepsy since age 12 2 4 complex partial seizures per month
Failed treatment with Dilantin, Tegretol, Depakote, Neurontin, Lamictal, Keppra

Case 1 Right Temporal Spikes

Case 1 Right Temporal Seizure

Case 1 - MRI

Case 1

Neuropsychological testing

Visual memory impairment

Wada Test

Left hemisphere language dominant 10/11 - right injection 2/8 - left injection

Case 1 - Outcome

Right Temporal Lobectomy May 2001

No neurological deficits

Remains seizure free

Case 2

23 y.o. man with epilepsy since age 9

6 8 complex partial seizures per month Failed treatment with Dilantin, Tegretol, Depakote, Lamictal,

Case 2 - Left Temporal Seizure

Case 2 - MRI

Case 2 PET scan

Case 2

Neuropsychological testing Mild verbal memory disturbance Wada Test Left hemisphere language dominant 9/10 - right injection 5/6 - left injection

Case 2 - Subdural Electrodes and Brain Mapping

Case 2 - Outcome

Left temporal lobectomy January 2002

No neurological deficits

Remains seizure free, off medication now

Other Surgical treatments

Corpus Callosotomy Hemispherectomy Multiple subpial transections Vagal Nerve Stimulation

Vagal Nerve Stimulation

Figure 1: The Vagus Nerve Stimulator: NCP 101 generator (with leads attached). Reprinted with permission of Cyberonics, Webster, Texas.

Vagal Nerve Stimulation

Reduces seizure frequency, not curative Avg reduction in sz frequency ~ 25% 1/3 of patients achieve greater than 50% reduction in sz frequency Special populations LGS with atonic/drop seizures have better response (20% with > 90%

Epilepsy Surgery: The Future

Gamma Knife Surgery Responsive Neurostimulation Deep Brain Stimulation

Responsive Neurostimulation

Responsive Neurostimulation

Responsive Neurostimulation Trial

Patients with LRE, with at least 4 seizures per month

SANTE Trial

Stimulation of the anterior thalamic nuclei LRE, with at least 6 seizures per month

Conclusions

Surgery may be curative

Surgical options should be considered early in the course of treatment