Epilepsy surgery

Overview

Epilepsy surgery is performed to either remove the brain area where seizures begin or stop the spread of seizure activity. It is a treatment option for people with seizures that are not controlled with medication. "Medically intractable seizures" are defined as persistent seizures despite trials of three or more antiepileptic drugs, alone or in combination. The goal of surgery is to to achieve better seizure control without causing loss of brain function.

What is epilepsy surgery?

Epilepsy surgery is a procedure to 1) remove the seizure-producing area of the brain or 2) limit the spread of seizure activity. Surgical results can be considered curative (stopping the seizures) or palliative (restricting the spread of the seizure). The type of surgery performed depends on the type of seizures and where they begin in the brain (Fig 1).

Curative procedures, such as lobectomy, cortical excision, or hemispherectomy aim to remove the area of the brain (seizure focus) causing seizures. The goal is to remove all of the seizure focus area without causing loss of brain function. Palliative procedures, such as corpus callosotomy or vagus nerve stimulation (VNS), aim to reduce seizure frequency or severity. People who are considered for surgery undergo extensive testing to locate the source of their seizures and to ensure that removing that region of the brain will not impact their speech, mobility or quality of life [2,3].

Types of epilepsy surgery

Curative procedures are performed when tests consistently point to a specific area of the brain where the seizures begin.

• Temporal lobectomy is the most common type of surgery for people with temporal lobe epilepsy. It removes a part of the anterior temporal lobe along with the amygdala and hippocampus. A temporal lobectomy leads to a significant reduction or complete seizure control about 70% to 80% of the time [4, 5]. However, memory and language can be affected if this procedure is performed on the dominant hemisphere.
• Cortical excision is the second most common type of epilepsy surgery. It removes the outer layer (cortex) of the brain at the seizure focus area. About 40% to 50% of patients have better seizure control.
• Hemispherectomy involves the removal of the brain's outer layer (cortex) and anterior temporal lobe on one half of the brain. It is usually performed in children who suffer intractable seizures, have a damaged hemisphere, and experience weakness on one side of the body. Surgery may control seizures for nearly 80% of these patients. Patients often improve in cognitive functioning, attention span, and behavior.

Palliative procedures are performed when a seizure focus cannot be determined or it overlaps brain areas critical for movement, speech, or vision.

• Corpus callosotomy prevents the spread of generalized seizures from one side of the brain to the other by disconnecting the nerve fibers across the corpus callosum. During surgery the anterior two thirds of the corpus callosum is sectioned. On occasion, a second surgery is performed to cut the posterior one third if the patient does not improve. This surgery is not curative. Rather, it prevents the spread and reduces seizure severity. Some patients experience disconnection syndrome after a complete callosotomy. They may have right-left confusion with motor problems, apathy, or mutism.
• Multiple subpial transections create small incisions in the brain to interfere with the spread of seizure impulses. This technique is used when the seizure focus is located in a vital area that cannot be removed. It may be used alone or in combination with a lobectomy.
• Vagus nerve stimulation (VNS) involves implantation of a device that produces electrical signals to prevent seizures. VNS is similar to a heart pacemaker. A wire (lead) is wrapped around the vagus nerve in the neck. The wire is connected to a generator-battery implanted under the skin near the collarbone. The generator is programmed to produce intermittent electrical signals that travel along the vagus nerve to the brain. In addition, some patients may turn on the device with a magnet when feeling a warning (aura) that a seizure is about to start. VNS is not a cure for epilepsy, it does not work for everyone, and it does not replace the need for anti-epileptic drugs. This procedure is reserved for those who are not candidates for potentially curative brain surgery. VNS reduces seizure frequency by about 30% (similar to the results of the newer AEDs) [6]. Common side effects are a tingling sensation in the neck and mild hoarseness in the voice, both of which occur only during stimulation.

Who is a candidate?

Epilepsy surgery may be an option if you have:

• seizures that are uncontrolled with medications (intractable) or you have severe side effects to the medications
• focal (partial) seizures that always start in one area of the brain (localized seizure focus)
• seizures that significantly affect your quality of life
• seizures caused by a lesion such as scar tissue, a brain tumor, arteriovenous malformation (AVM), or birth defect
• seizure discharge that spreads to the whole brain (secondary generalization)

Most experts recommend that a patient who continues to have seizures after trials of 2 or 3 different medications should have an evaluation at a comprehensive epilepsy treatment program. likelihood of seizure freedom after failure of 3 different medications is less than 5% [1, 2]. The epilepsy team typically consists of epileptologists (neurologists with special expertise in epilepsy), neurosurgeons, neuropsychologists, epilepsy nurse clinicians, and EEG technicians.

Patients are initially evaluated by an epileptologist. A complete medical history and physical exam helps identify critical information, such as age of onset and type of seizures (including frequency, severity, and duration) (see Seizures). A patient’s physical exam is usually normal. However, some asymmetries may be seen related to early development when the structural brain lesions formed. For example, a difference in the size of one hand or foot compared to the other may correlate with atrophy of one of the brain’s hemispheres.

The following diagnostic studies may be used during an evaluation for epilepsy surgery. Not all tests are required. The epilepsy team will decide which tests are appropriate.

• Continuous video-EEG monitoring requires a hospital stay in an epilepsy monitoring unit. For the EEG, a technician glues electrodes onto your scalp to record the electrical activity of the brain. With safe and continuous monitoring, movement/behavior and EEG activity are captured during a seizure with simultaneous recordings by video camera and electroencephalogram (EEG). Careful analysis of activity and brain waves both during and between seizures can provide critical information about where the seizure starts and spreads. Certain behaviors during seizures, such as abnormal posturing of an arm, or specific speech problems during or after a seizure, help your physician to identify where in the brain the seizure begins.
• Magnetic Resonance Imaging (MRI) helps identify structural brain abnormalities that can cause epilepsy. These include hippocampal atrophy, cavernous angiomas, cortical dysplasias, and tumors.
• Positron Emission Tomography (PET) allows the doctor to study brain function by observing how glucose (sugar) is metabolized in the brain. A small amount of radioactive glucose is injected into your bloodstream. The PET scanner takes pictures of the brain that are interpreted by a computer to examine glucose metabolism. Glucose use can increase (hypermetabolism) during a seizure and decrease (hypometabolism) when not having a seizure. These results may help locate areas of dysfunctional brain or other abnormalities, which could correspond to EEG localization of epileptogenic activity.
• Single-Photon Emission Computed Tomography (SPECT) provides information about blood flow to brain tissue. Analyzing blood flow to the brain may help determine how specific areas are functioning. Blood flow to an area of the brain during a seizure increases, while blood flow to an area of the brain can decrease when a person is not having a seizure.
• Neuropsychological testing evaluates your current level of brain functioning, including memory and language. This test might correlate with diagnostic imaging and EEG.
• Wada Test (Intracarotid Amytal test) is used to determine which side of your brain is dominant for language and memory function. Identifying the dominant side, the surgeon plans the operation to avoid affecting these functions. The Wada test, which is performed as part of an angiogram, can show any vascular or blood flow problems (see Angiogram). Sodium amytal is a short-acting barbiturate that is injected into the carotid artery on the right or left side. For a short time, the drug puts one half of the brain (hemisphere) to sleep. You cannot move one side of your body and may be unable to speak. Next, you are asked to identify pictures, words, objects, or numbers. After 5 to 10 minutes when the drug wears off, you are asked if you remember what was shown. The Wada test is then repeated on the other side. Used with neuropsychological testing, results of the Wada test help identify memory and language deficits and predict surgical outcome.
• Functional MRI (fMRI) is used to determine the location of brain abnormalities in relation to areas of the brain responsible for speech, memory, and movement. FMRI also helps doctors predict the functional outcome of surgical treatment. FMRI is sometimes used instead of a Wada test.

Electrical brain mapping, or electrocorticography, are diagnostic tests that may be necessary if the seizure focus is believed to lie close to important functional areas or if the exact location of the seizure focus remains unclear despite standard EEG and other tests. During a craniotomy operation for these diagnostic tests, subdural or depth electrodes are placed directly on or in the brain through a hole in the skull (craniotomy).

• Subdural electrodes aligned on a plastic grid, are placed directly on the brain’s surface (Fig 2). Subdural electrodes allow for a wide area of EEG recording as well as cortical mapping of functional areas.

Figure 2. Subdural electrodes are placed directly on the brain surface to record electrical activity.

• Intracerebral depth electrodes look like a banded stick. These are placed stereotactically deep into the brain tissue, usually the amygdala and hippocampus of the temporal lobe. Depth electrodes are indicated for patients with bitemporal, bifrontal, or frontal temporal seizures.

After the electrodes are placed, the wound is completely closed and bandaged. The patient is then moved to the epilepsy monitoring unit (EMU). The EEG technician will connect the electrodes (via wires that pass through small incisions in the skin) to an EEG machine that shows the brain waves and seizure activity. The patient remains in the hospital until sufficient information has been gathered to guide further treatment (typically 5-10 days). If the seizure focus is found and is not in an area of the brain involved in communication, a second surgery may be recommended to remove that brain area. If the seizure focus is not found, the electrodes are removed; follow up consultation with the epileptologist and neurosurgeon will follow. Risks associated with electrical brain mapping include infection and hemorrhage in about 2% to 5% of cases.

The surgical decision

The epilepsy team meets to review all testing performed to decide if surgery is the best treatment option. All tests should point to a single region in the brain as the source for seizures. If this is the case, and the region of seizure onset is a safe distance away from areas of the brain that control language, movement, and vision, then surgery can be recommend to reduce or eliminate seizures.

Who performs epilepsy surgery?

Epilepsy surgery is done by a neurosurgeon specifically trained in this field. A patient should have a presurgical evaluation at a comprehensive epilepsy treatment program by a multidisciplinary team of specialists (neurologists, neurosurgeons, neuropsychologists, and nurse clinicians).

What happens before surgery?

During the office visit, the neurosurgeon will explain the procedure, its risks and benefits, and answer any questions. You will sign consent forms and complete paperwork to inform the surgeon about your medical history (i.e., allergies, medicines, vitamins, bleeding history, anesthesia reactions, previous surgeries). Discuss all medications (prescription, over-the-counter, and herbal supplements) you are taking with your health care provider. Some medications need to be continued or stopped the day of surgery. Presurgical tests (e.g., blood test, electrocardiogram, chest X-ray) may need to be done several days before surgery. Consult your primary care physician about stopping certain medications and ensure you are cleared for surgery.

Stop taking all non-steroidal anti-inflammatory medicines (ibuprofen, naproxen, etc.) and blood thinners (Coumadin, aspirin, Plavix, etc.) 7 days before surgery. Stop using nicotine and drinking alcohol 1 week before and 2 weeks after surgery to avoid bleeding and healing problems.

You may be asked to wash your skin and hair with Hibiclens (CHG) or Dial soap before surgery. It kills bacteria and reduces surgical site infections. (Avoid getting CHG in eyes, ears, nose or genital areas.)

Don’t eat or drink after midnight before surgery (unless the hospital tells you otherwise).

Morning of surgery

• No food, drink, gum or candy.
• Shower using antibacterial soap. Dress in freshly washed, loose-fitting clothing.
• Wear flat-heeled shoes with closed backs.
• If you have instructions to take regular medication the morning of surgery, do so with small sips of water.
• Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
• Leave all valuables and jewelry at home.
• Bring a list of medications with dosages and the times of day usually taken.
• Bring a list of allergies to medication or foods.
• Take your anti-seizure medication as usual.

Arrive at the hospital 2 hours before your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. You will meet with a nurse who will ask your name, date of birth, and what procedure you’re having. They will explain the pre-operative process and discuss any questions you may have. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks.

What happens during surgery?

There are five main steps to the anterior temporal lobectomy. The surgery generally takes 3 to 4 hours.

Step 1: prepare the patient
You will lie on your back on the operative table and be given anesthesia. Once asleep, your head is placed in a skull fixation device attached to the table that holds your head in position during the surgery. Depending on where the incision will be made, your hair may be shaved.

Step 2: perform a craniotomy
After your scalp is prepped, the surgeon will make a skin incision to expose the skull. A circular opening in the skull, called a craniotomy, is drilled (see Craniotomy) (Fig 3). This bony opening exposes the protective covering of the brain, called the dura mater, which is opened with scissors.

Figure 3. In an anterior temporal lobectomy, a bone flap (craniotomy) is cut in the skull to expose the brain. A part of the temporal lobe is removed along with the amygdala and a portion of the hippocampus (grey area).

Step 3: perform brain mapping
Depending on your specific case, intraoperative EEG recording and stimulation with subdural electrodes may be performed to map brain areas (Fig. 4), or reconfirm the epileptic zone, particularly how much of the lateral temporal cortex is involved. Using a small electrical probe, the surgeon tests locations on the brain’s surface one after another to create a map of functions. During mapping, areas involved with movement can be identified electrically even if the patient is under anesthesia. However, to map areas such as language, sensation, or vision, the patient is awakened to be able to communicate with the surgeon. Local anesthesia and numbing agents are given so you won’t feel any pain.

Figure 4. Brain mapping with electrodes placed directly on the brain confirms the area of seizure focus before brain tissue is removed.

Step 4: remove the seizure focus area
Looking through an operative microscope, the surgeon gently retracts the brain and opens a corridor to the seizure focus area. The surgeon then removes that area of brain where seizures occur.

Step 5: close the craniotomy
The retractors are removed and the dura is closed with sutures. The bone flap is replaced and secured to the skull with titanium plates and screws. The muscles and skin are sutured back together.

What happens after surgery?

After surgery you'll be taken to the recovery room, where vital signs are monitored as you awake from anesthesia. You'll be transferred to the neuroscience intensive care unit (NSICU) for overnight observation and monitoring. Pain medication will be given as needed. If you experience nausea and headache after surgery, medication can be given to control these symptoms. Once your condition is stable, you will be moved to a regular room where you will stay for about 1 to 3 days.

If you had a VNS implanted, you may go home after recovery from anesthesia. It is important to work with your neurologist to adjust your medications and refine the programming of the neurostimulator.

Follow the surgeon’s home care instructions for 2 weeks after surgery or until your follow-up appointment. In general, you can expect:

Restrictions

• Don’t lift anything heavier than 5 pounds.
• No strenuous activity including yard work, housework, and sex.
• Don’t drink alcohol. It thins the blood and increases the risk of bleeding. Also, don’t mix alcohol with pain medicines.
• Don’t smoke or use nicotine products: vape, dip, or chew. It may delay healing.
• Don’t drive, return to work, or fly air travel until your surgeon says it’s OK.

Incision Care

• You may shower the day after surgery and wash your hair with mild baby shampoo. Gently wash the incision area with soap and water every day. Don’t scrub or let the water beat hard on your incision. Pat dry.
• If Dermabond skin glue covers your incision, don’t rub or pick at the glue.
• Don’t submerge or soak the incision in a bath, pool or tub. Don’t apply lotion/ointment on the incision, including hair styling products.
• You may hear strange noises (popping, crackling, ringing) inside your head. This is normal healing as air and fluid reabsorb.
• Don’t color your hair for 6 weeks. If you cut your hair, use caution near the incision.

Medications

• Headaches are common after surgery. You may take acetaminophen (Tylenol).
• Take pain medicines as directed by your surgeon. Reduce the amount and frequency as your pain subsides. If you don’t need the pain medicine, don’t take it.
• Narcotics can cause constipation. Drink lots of water and eat high-fiber foods. Stool softeners and laxatives can help move the bowels. Colace, Senokot, Dulcolax and Miralax are over-the-counter options.
• Anti-seizure medicine may be prescribed. Some patients develop side effects such as drowsiness, balance problems, or rashes. Call the office if any of these occur.
• Don’t take anti-inflammatory pain relievers (Advil, Aleve), blood thinners, or supplements without surgeon’s approval.

Activity

• Get up and walk 5-10 minutes every 3-4 hours. Gradually increase walking as you are able.
• Swelling and bruising of the eye or face may occur. It will take several weeks to go away.
• Sleep with your head elevated and apply ice 3-4 times per day for 15-20 minutes to help reduce pain and swelling.

When to Call Your Doctor

• Fever over 101.5º (unrelieved by Tylenol).
• Signs of incision infection, such as spreading redness, separation, or colored drainage.
• Increased drowsiness, weakness of arms / legs, increased headaches, vomiting, or severe neck pain that prevents lowering your chin to chest.
• New or worsening vision, speech or confusion.
• Swelling at the incision with leaking of clear fluid from your ear or nose.
• Swelling and tenderness in the calf of one leg.
• Seizure

Recovery

Patients usually can resume their normal activities after 3 to 4 weeks. However, you cannot drive an automobile until you have approval from your neurologist. Doctors usually recommend that surgical patients stay on AEDs for up to two years after the operation. Some people may have to continue with medication indefinitely for seizure control. If language or memory problems continue past the recovery period, your doctor may recommend speech or physical therapy.

What are the risks?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to a craniotomy may include:

• stroke
• seizures
• swelling of the brain, which may require a second craniotomy
• nerve damage, which may cause muscle paralysis or weakness
• CSF leak, which may require repair
• loss of mental functions
• permanent brain damage with associated disabilities

Specific complications may include:

• Memory and language problems after temporal lobectomy
• Temporary double vision after temporal lobectomy
• Increased number of seizures after corpus callosotomy, but the seizures should be less severe
• Reduced visual field after a hemispherectomy
• Partial, one-sided paralysis after a hemispherectomy; intense rehabilitation often brings back nearly normal abilities

Sources & links

If you have more questions, please contact Mayfield Brain & Spine at 800-325-7787 or 513-221-1100.

Sources

1. Wiebe S, Blume WT, Girvin JP, Eliasziw M: A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 345:311-8, 2001
2. Yasuda CL, Tedeschi H, Oliveira EL, et al: Comparison of short-term outcome between surgical and clinical treatment in temporal lobe epilepsy: a prospective study. Seizure 15(1):35-40, 2006.
3. Engel J Jr, Wiebe S, French J, Sperling M, et al: Practice parameter: temporal lobe and localized neocortical resections for epilepsy. Epilepsia 44(6):741-751, 2003.
4. Sperling MR, O'Connor MJ, Saykin: Temporal lobectomy for refractory epilepsy. JAMA 276(6):470-475, 1996.
5. Dupont S, Tanguy ML, Clemenceau S, et al: Long-term prognosis and psychosocial outcomes after surgery for MTLE. Epilepsia 47(12):2115-24, 2006.
6. Schachter SC: Vagus nerve stimulation therapy summary. Neurology 59:S15-20, 2002.

Links
Epilepsy Foundation Epilepsy.com
American Epilepsy Society AESnet.org

Glossary

antiepileptic drug (AED): a medication used to control epileptic seizures.

cortical mapping: direct brain recording or stimulation to identify language, motor, and sensory areas of the cortex.

cortex: the outer layer of the brain containing nerve cell bodies.

disconnection syndrome: the interruption of information transferred from one brain region to another.

generalized seizure: a seizure involving the entire brain.

hippocampal atrophy: a wasting or decrease in size of the hippocampus.

hypermetabolism: faster than normal metabolism.

hypometabolism: slower than normal metabolism.

ictal: that which happens during a seizure.

interictal: that which happens between seizures.

intractable: difficult to control.

localization: finding the location in the brain where epileptic seizures start.

lobectomy: surgical removal of a lobe of the brain.

seizure focus: a specific area of the brain where seizures begin.

palliative: to alleviate without curing.

partial seizure: a seizure involving only a portion of the brain.

video EEG monitoring: simultaneous monitoring of a patient’s behavior with a video camera and the patient’s brain activity by EEG

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updated: 1.2021
reviewed by: George Mandybur, MD, Mayfield Clinic, Cincinnati, Ohio