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

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