Epilepsy SurgeryEpilepsy SurgeryE Feoli MDE Feoli MD

North East Regional Epilepsy North East Regional Epilepsy GroupGroup20122012

ReferralsComprehensive

EpilepsyCenter

Evaluation:●History/Exam

●EEG●Imaging

Controlled Not Controlled

Video-EEG

Non-epilepticEvents

Epilepsy

MedicalManagement

SurgicalManagementRefer

The Poorly Controlled, Intractable The Poorly Controlled, Intractable Seizure PatientSeizure Patient

Despite medical management, patient Despite medical management, patient continues to have frequent, debilitating continues to have frequent, debilitating seizuresseizures

Commonly on polytherapy (more than one Commonly on polytherapy (more than one medication)medication)

Candidates for Candidates for Epilepsy SurgeryEpilepsy Surgery

Persistent seizures after initial attempts at Persistent seizures after initial attempts at treatment (at least 2 appropriate AEDs at treatment (at least 2 appropriate AEDs at reasonable doses)reasonable doses)

Impaired quality of life due to ongoing Impaired quality of life due to ongoing seizures seizures

For focal resection: single seizure focus For focal resection: single seizure focus that can be safely removedthat can be safely removed

Palliative procedures: corpus callosotomy, Palliative procedures: corpus callosotomy, subpial transections, VNS, otherssubpial transections, VNS, others

Epilepsy SurgeryEpilepsy Surgery To determine where the seizures are coming To determine where the seizures are coming

fromfromVideo-EEG monitoringVideo-EEG monitoringMRIMRIMRSMRS: : PETPET: : SPECTSPECT: :

Goals of Video-EEG MonitoringGoals of Video-EEG Monitoring Epilepsy vs. non-Epilepsy vs. non-

epileptic eventsepileptic events

Characterize epilepsy Characterize epilepsy typetype

Pre-surgical evaluationPre-surgical evaluationFOCAL EPILEPSY FOCAL EPILEPSY

EEG Slide

99-10-31/ROUTINE

Fp1-F7

F7-FT9

FT9-T7

T7-P7

P7-O1

Fp2-F8

F8-FT0

FT0-T8

T8-P8

P8-O2

FT9-FT0

A1-A2

Fp1-F3

F3-C3

C3-P3

P3-O1

Fp2-F4

F4-C4

C4-P4

P4-O2

ECG-RFECG-RF

SaO2(%)

HR(bpm)

Comment

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

spike

Fp1-F7

F7-FT9

FT9-T7

T7-P7

P7-O1

Fp2-F8

F8-FT0

FT0-T8

T8-P8

P8-O2

FT9-FT0

A1-A2

Fp1-F3

F3-C3

C3-P3

P3-O1

Fp2-F4

F4-C4

C4-P4

P4-O2

ECG-RF

SaO2(%)

HR(bpm)

Comment

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Brain MRIBrain MRI

MRIMRI

MRIMRI

SPECT SCANSPECT SCAN

PET SCANPET SCAN

Epilepsy SurgeryEpilepsy Surgery To make sure that it is safeTo make sure that it is safe

Wada testWada test: to study speech and memory: to study speech and memoryNeuropsychological testingNeuropsychological testing: mental functions (IQ, : mental functions (IQ,

memory, attention) and personality assessment memory, attention) and personality assessment Psychological evaluationPsychological evaluationOphthalmologic evaluationOphthalmologic evaluation

Epilepsy SurgeryEpilepsy Surgery Some cases in which the localization is not Some cases in which the localization is not

clear or where function could be affected will clear or where function could be affected will require INVASIVE ELECTRODESrequire INVASIVE ELECTRODES

Depth electrodesDepth electrodes Subdural electrodesSubdural electrodes

Subdural ElectrodesSubdural Electrodes

Types of Epilepsy SurgeryTypes of Epilepsy Surgery

Temporal LobectomyTemporal Lobectomy Extratemporal Extratemporal

ResectionsResections HemispherectomyHemispherectomy Corpus CallosotomyCorpus Callosotomy

Outcome after epilepsy surgeryOutcome after epilepsy surgery Anterior temporal lobectomyAnterior temporal lobectomy

70-80% seizure free70-80% seizure free Neocortical resectionNeocortical resection

With lesion: 50-80% seizure freeWith lesion: 50-80% seizure free Without lesion: 30-50% seizure freeWithout lesion: 30-50% seizure free

HemispherectomyHemispherectomy Significant improvementSignificant improvement

Corpus CallosotomyCorpus Callosotomy Significant improvement for drop attacksSignificant improvement for drop attacks

Complications of surgeryComplications of surgery Low rate of Low rate of

complicationscomplications InfectionsInfections BleedingBleeding AnesthesiaAnesthesia Function Function

Vagus Nerve Stimulator (1997)Vagus Nerve Stimulator (1997) Intractable epilepsy patient without focus or desires Intractable epilepsy patient without focus or desires

interim step before epilepsy surgeryinterim step before epilepsy surgery Goal is to reduce amount/severity of seizures vs. cureGoal is to reduce amount/severity of seizures vs. cure Device surgically implanted in left chest/axilla areaDevice surgically implanted in left chest/axilla area Coils around left vagus nerveCoils around left vagus nerve Stimulation is automatic; patient can additionally Stimulation is automatic; patient can additionally

stimulate device if aura stimulate device if aura

VNS Therapy VNS Therapy

VNS: <10% seizure free,VNS: <10% seizure free,

30-50% with at least 50% seizure 30-50% with at least 50% seizure decrease, more with lesser improvement; decrease, more with lesser improvement; effects on seizure severity?effects on seizure severity?

Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)

NeuropaceNeuropace

ConclusionConclusion-Not all patients with refractory -Not all patients with refractory

epilepsy are surgical candidates.epilepsy are surgical candidates.-Patients with -Patients with FOCAL refractory refractory

epilepsy are candidates for surgery.epilepsy are candidates for surgery.-Multiple steps are required before -Multiple steps are required before

your doctor concludes that you are your doctor concludes that you are a surgical candidate. a surgical candidate.

--

ConclusionConclusion

You might be a good surgical You might be a good surgical candidate however a candidate however a RESECTIVE procedure might RESECTIVE procedure might not be possible, due to the not be possible, due to the proximity o the seizure focus proximity o the seizure focus to “eloquent cortex”to “eloquent cortex”

Thank youThank you