SURGICAL MANAGEMENT OF EPILEPSY

• Brief alterations of awareness
• Activity arrest, starring, automatisms
• Pick-up where they left-off
• Average age 8-10years
• Classic EEG Pattern of 3Hz/sec
• Females slightly more than males
• Hyperventilation provokes onset

• Any age onset and M=F
• Stiff extension of body/extremities followed by violent, rhythmic, symmetric movements
• Alteration of consciousness followed by confusion and sleepiness
• Changes in respiration, bladder and bowel

• Brief, random, lightning-like movements
• May occur singly or in clusters
• Seconds in duration, no post-ictal changes
• Various age onset
• Can be resistant to therapy

• Sustained flexion and/or contraction of major muscle groups
• Component of Lennox-Gastaut syndrome
• Often associated with respiratory arrest
• May be associated with coarse tremor

• Symmetric, rhythmic movements of extremities as in Tonic/Clonic seizures
• Often occur out of sleep

• Abrupt loss of tone
• Frequently associated with trauma
• Positive alteration consciousness with variable post-ictal changes

• Partial seizures
• Simple partial seizures
• Complex partial seizures
• Impaired consciousness at outset
• Simple partial evolving to lost consciousnes
• Partial seizures evolving to general tonic-clonic seizures (GTCS)

• Often called Benign Rolandic
• Hallmark is preservation of consciousness
• Classic pattern on EEG
• M=F, average age onset 7-8
• +/- therapy necessary
• Often “outgrown”
• May not be “so benign”

• Change in consciousness
• Most common epilepsy in children
• Automatisms, deja vue, auras or alice in wonderland changes seen
• Focal motor movements of any limb
• Variable duration and severity
• Any age onset

• Sodium channel effects
• Potassium channels and GABA release
• GABAergic effects
• Precursors, mimicry, and transporters
• Glutamate regulation-neuroprotection
• Calcium channels and transmitter release

• They have failed at least 3 adequate anti-convulsant trials
• Definition of failure varies
• EEG confirming epilepsy
• Recent MRI
• Family/patient willing to consider surgery

• Focal
• Lesion
• Anatomically Normal
• Temporal
• Extra-Temporal
• Multi-Focal/Generalized

• 20% of epilepsy patients
• Mental retardation
• Autism
• Neuropsychiatric syndromes

• Heterotopias - A failure of neuronal migration from the periventricular matrix to the cortex; asymptomatic or mental retardation or seizure
• Agyria - No gyri (lissencephaly) or a few malformed gyri (pachygyria)
• Polymicrogyria - Excessive number of gyri are formed with shallow sulci; sporadic (congenital ischemia/hypoxia, infection) or familial; asymptomatic, mental retardation or seizure
• Focal cortical dysplasia

• Heterotopias - A failure of neuronal migration from the periventricular matrix to the cortex; asymptomatic or mental retardation or seizure
• Agyria - No gyri (lissencephaly) or a few malformed gyri (pachygyria)
• Polymicrogyria - Excessive number of gyri are formed with shallow sulci; sporadic (congenital ischemia/hypoxia, infection) or familial; asymptomatic, mental retardation or seizure
• Focal cortical dysplasia

• Heterotopias - A failure of neuronal migration from the periventricular matrix to the cortex; asymptomatic or mental retardation or seizure
• Agyria - No gyri (lissencephaly) or a few malformed gyri (pachygyria)
• Polymicrogyria - Excessive number of gyri are formed with shallow sulci; sporadic (congenital ischemia/hypoxia, infection) or familial; asymptomatic, mental retardation or seizure
• Focal cortical dysplasia

• Heterotopias - A failure of neuronal migration from the periventricular matrix to the cortex; asymptomatic or mental retardation or seizure
• Agyria - No gyri (lissencephaly) or a few malformed gyri (pachygyria)
• Polymicrogyria - Excessive number of gyri are formed with shallow sulci; sporadic (congenital ischemia/hypoxia, infection) or familial; asymptomatic, mental retardation or seizure
• Focal cortical dysplasia

TAKE THEM OUT!!!

Consider monitoring, either with surface EEG or with implanted grids.  However, once lesion is confirmed to be source of epileptiform discharges, TAKE THEM OUT!!!

• Work-up includes: Stage I
• Surface EEG-Video Monitoring
• Head MRI with and without contrast
• Neuropsychological testing
• Stage II
• Invasive EEG
• Grids, strips, and depth electrodes
• Functional Imaging
• Wada, PET, SPECT, fMRI

• Temporal lobe epilepsy            
• 90% were seizure free
• 98% had a >90% reduction in seizures¹
• Extra-temporal lobe epilepsy
• 70% were seizure-free²

1 Cukiert et al: Neurosurg Focus. 2002 Oct 15;13(4):ecp2
2 Kazemi et al: Epilepsia. 1997 Jun;38(6):670-7.

• Corpus Callosotomy    
• More commonly used in patients with Lennox-Gastaut or drop attacks
• 30% of patients were seizure-free¹
• Vagus Nerve Stimulation
• 88% of patients had a >50% reduction in seizures
• 20-30% of patients became seizure-free
• Average reduction in anti-convulsant dose was 1/3
• Utilization increasing, with 7,000 VNS implanted/year for epilepsy

1 Phillips et al: Br J Neurosurg. 1996 Aug;10(4):351-6.

• Implantable pulse generator and lead
• Mild electrical pulses applied to the left vagus nerve in the neck send signals to the brain
• Automatic intermittent stimulation
• Magnet use allows patient/caregiver
• On-demand stimulation
• On-demand side effect control
• Simple in-office programming
• Assured compliance

• Creation of left chest sub-cutaneous pocket
• Cut-down to left vagus nerve
• Attachment of lead to nerve
• Tunneling on lead
• Lead test
• Programming
• Closure

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