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Epilepsy: Types of Surgery

Epilepsy surgery is very effective in cases in which the source of the seizure can be precisely localized in the brain. This usually happens in cases of partial (focal) seizure, but some seizures that appear to be generalized may actually have an identifiable initiation point, and therefore may be amenable to surgery.

Assessment

Extensive evaluation is required before epilepsy surgery is considered as an option. Team members, including neurologists, neurological surgeons, neuroradiologists, neuropsychologists, nurse specialists, language therapists, and occupational and physical therapists, work together to trace the source of a seizure and identify the precise region of the brain responsible for their initiation. The team may use sophisticated diagnostic techniques, such an encephalograms (EEGs), video-EEG telemetry, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and functional MRI, are used to assess and visualize abnormalities and structural problems and identify the precise "source" of seizures. Not only does the team have to identify the source of a seizure, but they also must examine the brain to predict the effects of surgery on speaking, understanding, or other neurological functions. The goal of surgery is to devise an individualized treatment to obtain maximum seizure control with minimum consequent dysfunction or difficulties.

Types of Epilepsy Surgery

Lobectomy
The brain is divided into sections called lobes – frontal, temporal, occipital, and parietal. When the initiation point of a seizure can be traced to a particular region of a particular lobe, a portion of that lobe can be removed to prevent future seizures. These surgeries, especially temporal lobectomies, are among the most common surgical procedures for epilepsy; they are associated with high success rates and low complication rates. The risk of consequent neurological deficits is low because often because the tissue removed already is abnormal and does not contribute to everyday function.

Hemispherectomy
In some cases, particularly in children, one side of the brain is dramatically affected by severe disease, causing uncontrolled seizing. In these epilepsy cases, the limited resection of a lobectomy may not be enough to control the seizures and a hemispherectomy, in which as much as half of the brain is removed, may be considered. In these patients, the remaining side of the brain often takes over some of the functions of the other side, although there still will be side effects, including weakness and a loss of movement on one side of the body. The hemispherectomy that is performed today is a highly modified, specialized, and smaller operation than the removal of half of the brain. This procedure, known as "functional hemispherectomy," involves both resection and the disconnection of pathways along which seizures travel.

Corpus Callosotomy
When seizures are more generalized, often resection is out of the question. Interaction between the brain's hemispheres, however, may contribute to seizure severity. When this is the case, specialists may recommend corpus callosotomy, a surgical procedure that does not necessarily involve the removal of tissue. Rather, for this procedure, the connections between the two hemispheres of the brain are partially or completely severed. While this may not cure seizures, it has been shown to reduce seizure frequency and severity, or limit seizures to one side of the brain.

Multiple Subpial Transection
Somewhat similar to corpus callosotomy, multiple subpial transection is a surgical technique that limits seizures by severing the nerve pathways along which they propagate. To put it simply, vertical connections between nerves cells are thought to be associated with normal brain function, while horizontal connections appear to help seizures spread. Subpial transections involve cutting the horizontal connections to prevent seizures from spreading. This relatively new procedure can limit seizing and help protect functionally important regions of the brain.

Vagal Nerve Stimulation
Vagal nerve stimulation is a type of surgery for poorly controlled seizures that does not involve brain surgery or the removal of tissue. For this procedure, a small pacemaker-like device is implanted that periodically stimulates a nerve (the vagus) in the side of the neck with a small electrical current. Research suggests that stimulation of the vagus nerve can disrupt the abnormal brain activity responsible for seizures. The procedure has been shown to reduce seizure frequency and severity. Although vagal nerve stimulation is not as effective as surgery as stopping seizures, it is an excellent option for patients unable to undergo brain surgery.

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