Being an epilepsy surgeon is an extremely satisfying specialty. It is a unique privilege to be able to operate on someone's brain and, in many cases, cure a seizure disorder that some patients have had their whole lives.
Although most patients with epilepsy have excellent seizure control with medications alone, about one in five have seizures that are not controlled with medications. Though it is not an option for everyone, many of these patients may be candidates for epilepsy surgery - a special type of brain surgery performed by neurosurgeons to help treat epilepsy that cannot be treated with medications. For those who end up having surgery, the road to surgery can be a long one.
The most common type of epilepsy surgery is performed on patients with focal epilepsy, which means their seizures are coming from a specific location in the brain. Surgery for this type of epilepsy usually involves removing the part of the brain responsible for the patient's seizures. Surprisingly, many parts of the brain can be removed without causing any problems and, fortunately, most cases of focal epilepsy occur in these non-essential areas. However, all cases are treated individually and the risks and benefits of surgery need to be weighed thoroughly for each patient.
Patients being considered for epilepsy surgery are normally seen first by a neurologist who specializes in epilepsy. All patients have an MRI scan and a test called an electroencephalogram (EEG), which measures the brain's electrical activity. Next, patients are admitted to a special ward in the hospital that is used to monitor their seizures. They are hooked up to an EEG and monitored by a camera 24-hours a day. The goal is to capture seizures on video and for the neurologist to see what the brain activity looks like at the same time. Many other tests may be done during this hospital stay, including additional brain scans and psychological testing. The admission to the epilepsy unit lasts about a week, but can be longer in some circumstances. This hospital admission is often memorable and eye opening for patients as they meet other people with epilepsy and share stories with them and their families. They often realize that they are not alone.
After the hospital admission, the doctors meet to discuss the test results to decide if a patient is eligible for surgery. Occasionally, additional tests are required in order to reach a final decision. In about half of patients, it is decided that a more detailed EEG is required, one with intracranial electrodes. Unlike the regular EEG, which uses electrodes on the scalp, these electrodes are surgically placed inside the skull and may be either on the brain (called subdural electrodes), or in the brain (called depth electrodes). It is during this stage that patients will meet their surgeon and can discuss the details of the procedure and what risks may be involved. Patients are then brought back into the hospital for an operation to insert the electrodes. After surgery, they stay in the same epilepsy unit as before, only this time it is often a longer stay, lasting a week or two or even longer. Once the intracranial EEG is completed, the electrodes are removed and the patient is discharged. The doctors will then meet again to discuss the results of the tests and make a final decision about surgery.
Once a final decision is made about surgery, the doctor will meet with the patient to explain all of the test findings and let them know whether they are eligible for surgery. Not all patients turn out to be eligible for surgery. This can be due to the fact that the seizures are coming from too wide of an area or that they are coming from an important part of the brain that cannot be removed. This can be very disappointing, especially for those patients who have gone through the intracranial EEG phase. However, even though they are disappointed, most of these patients are content that they at least know with certainty that surgery is not an option for them. For the majority of people, however, surgery is possible and these patients then go on to meet the surgeon if they have not done so already.
The surgeon will explain the exact procedure in detail, the likelihood that the surgery will work and outline any potential side effects. Most patients have a general anesthetic for the procedure, however some patients need to be wakened during surgery test brain function.
On the eventual day of surgery patients are often nervous. After months of preparation, the actual surgery may last for only a few hours and the hospital stay only a few days after which patients can go home, hopefully seizure free!
By Dr. David Steven (@epilepsysurgeon). Dr. Steven is a neurosurgeon in London, Ontario. He is the co-director of the Epilepsy Program at the London Health Sciences Centre.
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