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Surgical Treatment of Epilepsy
Epilepsy Awareness DayColumbia Comprehensive Epilepsy Center
Anil Mendiratta, M.D.
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Definitions
Seizure
Epilepsy
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Types of seizures
Partial
Generalized
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Scope of the Problem
10% of the population will have aseizure in their lifetime
1% of the population suffers from
epilepsy3,000,000 4,000,000people
in the US
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Advances in the Management ofEpilepsy
Medical Treatment Surgical Treatment
Overall Approach
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Advances: Overall Approach
No seizures
No side effects
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Advances: Medical Treatment
Medications in use before 1993 Phenobarbital 1912
Phenytoin (Dilantin) 1938
Primidone (Mysoline) 1954
Ethosuximide (Zarontin) 1960
Carbamazepine (Tegretol) 1974
Valproate (Depakote) 1978
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Advances: Medical Treatment
New Medications since 1993 Felbamate (Felbatol) 1993
Gabapentin (Neurontin) 1993
Lamotrigine (Lamictal) 1994
Topiramate (Topamax) 1996
Tiagabine (Gabitril) 1997
Levetiracetam (Keppra) 1999
Zonisamide (Zonegran) 2000
Oxcarbazepine (Trileptal) 2000
Pregabalin (Lyrica) 2005
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Advances: Surgical Treatment
Comprehensive epilepsy centers Video-EEG monitoring
MRI, PET, SPECT, MEG, fMRI
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Who is a candidate?
Focal epilepsy
Resistant to medication
Disrupt quality of life
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Epilepsy Surgery
Focal cortical resection
Corpus callosotomy Hemispherectomy
Multiple subpial transections
Vagal Nerve Stimulation
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Brain
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Epilepsy Surgery: Objectives
Resect the epileptogenic focus
Preserve neurological function
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Epilepsy Surgery: Goals
Seizure Freedom
Improved Quality of Life
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Epilepsy Surgery: Outcomes
Structural Lesions (low grade tumors,
vascular malformations)
up to 80 - 90% seizure free
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Arteriovenous Malformation
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Epilepsy Surgery: Outcomes
Mesial Temporal Sclerosis
up to 80% seizure free
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MRI Right MTS
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Epilepsy Surgery: Outcomes
Non-lesional or dysplasia
up to 50% seizure free
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Surgical complications
5% complication rate 1-2% permanent
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Surgical Evaluation
Video-EEG monitoring
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Surgical Evaluation
Brain imaging - MRI, PET, SPECT
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Surgical Evaluation
Neuropsychological Testing
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Surgical Evaluation
Intracarotid Amobarbital (Wada)Test
Functional MRI
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Surgical Evaluation
+/- Intracranial Recording Cortical mapping
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Surgical Evaluation
Multidisciplinary Case Conference
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Case 1 Right Temporal Spikes
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Case 1 Right Temporal Seizure
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Case 1 - MRI
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Case 1
Neuropsychological testing
Visual memory impairment
Wada Test
Left hemisphere language dominant
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2/8 - left injection
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Case 1 - Outcome
Right Temporal Lobectomy May
2001
No neurological deficits
Remains seizure free
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Case 2
23 y.o. man with epilepsy since age 9
6 8 complex partial seizures permonth
Failed treatment with Dilantin,
Tegretol, Depakote, Lamictal,
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Case 2 - Left Temporal Seizure
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Case 2 - MRI
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Case 2 PET scan
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Case 2
Neuropsychological testing
Mild verbal memory disturbance
Wada Test
Left hemisphere language dominant
9/10 - right injection
5/6 - left injection
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Case 2 - Subdural Electrodes andBrain Mapping
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Case 2 - Outcome
Left temporal lobectomy January
2002
No neurological deficits
Remains seizure free, offmedication now
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Other Surgical treatments
Corpus Callosotomy
Hemispherectomy Multiple subpial transections
Vagal Nerve Stimulation
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Vagal Nerve Stimulation
Figure 1: The Vagus Nerve Stimulator: NCP 101 generator (with leads attached).Reprinted with permission of Cyberonics, Webster, Texas.
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Epilepsy Surgery: The Future
Gamma Knife Surgery
Responsive Neurostimulation
Deep Brain Stimulation
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Responsive Neurostimulation
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Responsive Neurostimulation
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Responsive NeurostimulationTrial
Patients with LRE, with at least 4seizures per month
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SANTE Trial
Stimulation of the anterior thalamicnuclei
LRE, with at least 6 seizures permonth
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Conclusions
Surgery may be curative
Surgical options should be
considered earlyin the course oftreatment