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Evaluating Your Options for Epilepsy Surgery

Posted on March 29, 2022
Medically reviewed by
Remi A. Kessler, M.D.
Article written by
Brooke Dulka, Ph.D.

Controlling epilepsy is not always easy. However, uncontrolled seizures can be dangerous for a person living with epilepsy. If medications alone are not enough to control seizure activity, a neurosurgeon or neurologist may recommend epilepsy surgery. Thanks to advances in science and medicine, there are more surgery options for epilepsy now than ever before.

What Is Surgery for Epilepsy?

Epilepsy surgeries typically involve removing a small part of the brain that is responsible for generating seizures. Epilepsy surgery might also involve implanting a device in the brain that helps control seizures.

Surgery for epilepsy can be a very effective treatment. Research shows that between 36 percent and 100 percent of adults and children who undergo epilepsy surgery are seizure-free for at least one year, depending on their type of epilepsy and the type of surgery.

Different Types of Surgery for Epilepsy

There are many types of surgery for different types of epilepsy. It is important that the type of surgical treatment is appropriately matched to a person’s type of epilepsy.

Focal Resection

A focal resection is when a surgeon removes the point in the brain from which seizures begin. Typically, this method is used when there is a brain abnormality that is causing seizures. This type of surgery is most successful when ​​the brain abnormality, as seen in MRI imaging, occurs in the same spot where seizures start based on electroencephalogram (EEG) monitoring. Brain mapping is also performed to determine the locations within the brain that are responsible for critical brain functions — such as speech, memory, movement, and vision — to avoid them during surgery. Research shows that a tailored resection of the site of a brain abnormality (such as a tumor or other lesion) that includes the seizure zone around it is more effective than a simple lesionectomy (only taking out the tumor itself).

A focal resection does not have to be a small area. Large portions of the temporal lobe or frontal lobe can be removed. According to the Epilepsy Foundation, the most common type of epilepsy surgery is an anterior temporal lobectomy (or resection of the lobe). This surgery also has the highest rate of success and is performed for certain people living with temporal lobe epilepsy.

Similarly, for frontal lobe epilepsy, a frontal lobe surgical resection may be performed. This is the second most common location for epilepsy surgery. People with frontal lobe epilepsy often have problems with cognitive abilities like concentrating, planning, or organizing. Frontal lobe resection has been shown to eliminate seizures in up to 50 percent of cases, while generally maintaining cognitive function after surgery.

Lesionectomy

Focal epilepsy can sometimes be controlled by removing the part of the brain in which focal seizures begin. This is usually done when the seizures are caused by structural anomalies (such as abnormal blood vessels, brain tumors, or scar tissue). Research has also shown that this type of surgery is successful in children with glioneuronal brain tumors.

Multiple Subpial Transections

In a multiple subpial transection procedure, a neurosurgeon makes a series of delicate, shallow cuts (transections) into the brain’s gray matter. This procedure can disrupt electrical activity across the brain and, thus, reduce seizure activity. This type of surgery is performed when focal seizures begin in places where resection is not an option — in parts of the brain that control critical functions like speech and movement, for example.

This type of surgery can also be done along with other types of epilepsy surgery. In one study of individuals who had multiple subpial transections plus resection surgery, excellent outcomes (greater than 95 percent decrease in seizure frequency) were observed in 87 percent of participants for generalized seizures, 68 percent for complex partial seizures, and 68 percent for simple partial seizures. For people who underwent multiple subpial transections without resection surgery, the rate of excellent outcomes was only a bit lower — 71 percent for generalized seizures, 62 percent for complex partial seizures, and 63 percent for simple partial seizures.

Laser Interstitial Thermal Therapy

Laser interstitial thermal therapy is very different compared to standard surgical resections for epilepsy. It does not involve opening up the skull or the brain, or removing any part of the brain. It is considered a minimally invasive procedure.

First, the area of the brain causing seizure activity is determined with an MRI scan. Then, an extremely accurate laser is used to destroy the seizure focus area discovered through the MRI imaging. This type of therapy has been shown to be effective for mesial temporal lobe epilepsy that cannot be controlled with medication.

Anatomical and Functional Hemispherectomy

An anatomical hemispherectomy is the removal of most of one side of the brain where seizure activity occurs. This is considered to be a very invasive course of treatment. It is usually only performed in children with severe epilepsy that is not responsive to other types of treatment. It can be a treatment option for children who have Rasmussen’s encephalitis, hemimegalencephaly, Sturge-Weber syndrome, or congenital malformations of brain development. It can also be an option for children who experienced large strokes around the time of birth.

A functional hemispherectomy is a form of epilepsy surgery that involves removing a small area of the side of the brain affected by seizures and then disconnecting the remaining tissue from the rest of the brain. Both anatomical and functional hemispherectomy have been used successfully to treat hemispheric epilepsy that does not respond to medical treatment.

Hemispherotomy

A hemispherotomy is different from hemispherectomy in that much less brain tissue is removed. This decreases the risk of complications from surgery. In this type of surgery, the surgeon makes a hole or several holes in the affected hemisphere to disrupt electrical activity. This technique is also used for hemispheric epilepsy not controlled by medication, hamartomas (benign masses of tissue) in the hypothalamus, and some other forms of epilepsy.

Corpus Callosotomy

In a corpus callosotomy, the large band of connective tissue that bridges the two hemispheres of the brain (the corpus callosum) is disconnected. This type of surgical procedure is used for severe generalized epilepsy. This surgery helps prevent excessive electrical activity from crossing from one side of the brain to the other. It is usually performed on children with severe epilepsy that does not respond to medication.

Stereotactic Radiosurgery

Stereotactic radiosurgery (SRS) involves using targeted radiation to treat the area of the brain where seizures start. Other common names for SRS include Gamma Knife and CyberKnife surgery. It is a minimally invasive technique, and no surgical incisions are made in the skin.

Neurostimulation Device Implants

Some forms of surgery do not involve removing or changing brain tissue. Rather, they involve implanting devices that can help reduce or manage seizures. Neurostimulation (brain stimulation) device implants include:

  • Vagus nerve stimulation (VNS) VNS involves the implantation of a small electrical generator under the skin over the chest. A wire (stimulator lead) is then attached to the vagus nerve in the neck, which goes to the brain. The nerve is stimulated regularly to reduce seizure activity. VNS is a viable and less-invasive treatment option for refractory epilepsy.
  • Responsive neurostimulation (RNS) — In this treatment option, stimulation is used when a seizure begins to stop or reduce the seizure. A small implant is placed within the bone above the brain. Leads are attached to the implant and placed onto the brain. These electrodes can then detect abnormal brain wave activity. RNS has been used successfully in adults to reduce the frequency of partial-onset seizures.
  • Deep brain stimulation (DBS) — DBS involves the implantation of a device inside the brain, typically the thalamus. This device helps reduce epileptic activity by “targeting” the deep brain structures responsible for seizures with electrical stimulation. The stimulation then changes how the brain works to reduce seizures.

Building a Community

MyEpilepsyTeam is the social network for people with epilepsy and their loved ones. On MyEpilepsyTeam, members come together to ask questions, give advice, and share their stories with others who understand life with epilepsy.

Are you or a loved one living with epilepsy? Have you tried any of the types of surgery mentioned in this article? Share your experience in the comments below, or start a conversation by posting on MyEpilepsyTeam.

References
  1. Epilepsy Surgery: About — Mayo Clinic
  2. Outcomes of Epilepsy Surgery in Adults and Children — The Lancet Neurology
  3. Types of Epilepsy Surgery — Epilepsy Foundation
  4. Seizure Outcome of Epilepsy Surgery in Focal Epilepsies Associated With Temporomesial Glioneuronal Tumors: Lesionectomy Compared With Tailored Resection — Journal of Neurosurgery
  5. Cognitive Outcome Two Years After Frontal Lobe Resection for Epilepsy — A Prospective Longitudinal Study — Seizure
  6. Lesionectomy — The Brain Recovery Project
  7. Multiple Subpial Transection for Intractable Partial Epilepsy: An International Meta-Analysis — Epilepsia
  8. Laser Interstitial Thermal Therapy for Medically Intractable Mesial Temporal Lobe Epilepsy — Epilepsia
  9. Pediatric Functional Hemispherectomy: Operative Techniques and Complication Avoidance — Journal of Neurosurgery
  10. Hemispherectomy — Cleveland Clinic
  11. Hemispherotomy and Other Disconnective Techniques — Journal of Neurosurgery
  12. Hemispherotomy: Efficacy and Analysis of Seizure Recurrence — Journal of Neurosurgery Pediatrics
  13. Corpus Callosotomy — Cleveland Clinic
  14. Corpus Callosotomy Outcomes in Pediatric Patients: A Systematic Review — Epilepsia
  15. Minimally Invasive Techniques for Epilepsy Surgery: Stereotactic Radiosurgery and Other Technologies — Journal of Neurosurgery
  16. Stereotactic Radiosurgery: About — Mayo Clinic
  17. Vagus Nerve Stimulation (VNS) — Epilepsy Foundation
  18. Vagus-Nerve Stimulation for the Treatment of Epilepsy — The Lancet Neurology
  19. Responsive Neurostimulation (RNS) — Epilepsy Foundation
  20. Two-Year Seizure Reduction in Adults With Medically Intractable Partial Onset Epilepsy Treated With Responsive Neurostimulation: Final Results of the RNS System Pivotal Trial — Epilepsia
  21. Deep Brain Stimulation (DBS) — Epilepsy Foundation
  22. Deep Brain Stimulation for Epilepsy — Cleveland Clinic
All updates must be accompanied by text or a picture.
Remi A. Kessler, M.D. received her medical degree from the Icahn School of Medicine at Mount Sinai in New York City. Learn more about her here.
Brooke Dulka, Ph.D. is a freelance science writer and editor. She received her doctoral training in biological psychology at the University of Tennessee. Learn more about her here.

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