Written by : Dr. Ashalatha Radhakrishnan, Consultant Neurologist & Epileptologist, India
Epilepsy surgery has been convincingly proved as a successful and viable treatment option in persons with medically refractory epilepsy world-over. India too has Epilepsy centers with state-of-the-art facilities to evaluate and surgically treat such difficult-to-treat epilepsies in par with any other major center. Therefore, persons with epilepsy should know all aspects of epilepsy surgery. The queries that cross patients’ minds when a physician offers “surgery” as a crucial treatment option are many.
Let us briefly address them one by one.
1. What is the role of surgery in persons with epilepsy?
Although a good majority of epilepsy sub-types can be controlled/cured by appropriate drug(s), still a group of them are unlikely to be relieved even with an appropriate combination of even two or more drugs. If one has such medically refractory epilepsy and the MRI scan of brain shows a lesion (e.g.an area of brain occupied by a foreign tissue like a tumor, scar, a developmental abnormality etc) they are unlikely to get adequate seizure control with drugs. They are
considered ideal surgical candidates. Few of them who have apparently no abnormality in MRI, but other investigations, especially a video-EEG (VEEG) which is a method of recording of seizures with an EEG running in parallel, pointing to a single focus of origin of seizures, are also surgical candidates.
2. How early should surgery be considered?
A simplistic approach to this pertinent question is,” If the person has failed trials of one or two drugs alone or in combination for at least 2 years”, the option of surgery arises. This two-year period is considered a tangible waiting period, but the current practice is to consider it “at the earliest” since the aforementioned lesions are unlikely to respond to drugs. In children, “catch them young” is the policy to be followed since longer duration of seizures, drugs and their side effects impairs their development in all spheres, especially intellectual, language, social and communication skills.
3. Whom should they approach for surgery?
Ideally, surgery is performed in a center where there is a comprehensive epilepsy care program comprising of a team of neurologists and neurosurgeons with experience in treating epilepsy, along with a psychologist, psychiatrist, occupational and speech therapist. Each case after the necessary investigations is discussed in a common meeting
before taking up for surgery (Figure 1a, b).
4. Are there any complications after epilepsy surgery?
The basic philosophy of epilepsy surgery is to do a focal removal or disconnection of an area of the brain without causing any permanent, disabling deficits to the person. Surgery is done under anesthesia through a microscope by opening a small plate of skull bone. This bone is replaced after the surgery. In best of hands and centers with ample expertise, complications are very few. Although it varies from case to case, approximately it is less than 0.5%. They
range from minor ones like fever, infection of the wound or operated site of brain, defective vision or one sided weakness of body etc. But these are very rare and the chance of one getting it will be explained before surgery in great detail.
5. What are the expenses and period of hospital stay involved?
The cost will vary from country to country but the average expense comes to an average of Rs. 75,000-1,50,000 in various centers and can vary depending on the type of surgery and additional procedures involved. A stay of 7-10 days in the hospital would suffice. Patient after a period of 2-3 weeks can then resume his/her routine activities.
6. Can medicines be stopped after surgery?
In most of the persons after a successful surgery, medicines can be totally stopped in a gradual manner in the next 1-2 years. In very few, a small dose of a single drug may have to be continued for various reasons.
7. Can one lead a normal life after surgery?
After a successful surgery, especially after stopping or reducing drugs, one can lead a very normal life like others. Employment, marriage, driving, socializing, all are possible.
- Surgery plays a crucial role in treatment of drugresistant epilepsy
- Identifying surgical candidates at the earliest gives better results
- Surgical candidates should be referred to a Comprehensive Epilepsy Care Centre for surgery
- Surgery improves the quality of life of a person by eradicating seizures and stopping or reducing drugs
Legend to figures
Figure1a. Video-EEGs done in the last 10 years in R. Madhavan Nayar Center for Comprehensive Epilepsy Care (RMNCEC) as part of presurgical workup.
Figure 1b. Epilepsy surgeries conducted for drugresistant epilepsy in the last 10 years in RMNCEC.