Epilepsy Surgery Epilepsy Surgery E Feoli MD E Feoli MD North East Regional North East Regional Epilepsy Group Epilepsy Group 2012 2012
Mar 26, 2015
Epilepsy SurgeryEpilepsy Surgery
E Feoli MDE Feoli MD
North East Regional Epilepsy North East Regional Epilepsy GroupGroup
20122012
ReferralsComprehensive
EpilepsyCenter
Evaluation:●History/Exam
●EEG●Imaging
Controlled Not Controlled
Video-EEG
Non-epilepticEvents
Epilepsy
MedicalManagement
SurgicalManagement
Refer
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 Persistent seizures after initial attempts at treatment (at least 2 appropriate AEDs at treatment (at least 2 appropriate AEDs at reasonable doses)at 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 monitoring
MRIMRI
MRSMRS: :
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 evaluation
FOCAL 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 safeWada testWada test: to study speech and memory: to study speech and memory
Neuropsychological testingNeuropsychological testing: mental functions (IQ, : mental functions (IQ, memory, attention) and personality assessment memory, attention) and personality assessment
Psychological evaluationPsychological evaluation
Ophthalmologic 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 epilepsy are candidates for surgery.surgery.
-Multiple steps are required before -Multiple steps are required before your doctor concludes that you your doctor concludes that you are a surgical candidate. are 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