Epilepsy surgery

Epilepsy surgery is defined as surgery carried out specifically to control epileptic seizures. This will include operations on tumours and vascular lesions where epilepsy is the primary indication for surgery. There is clearly an overlap with lesional surgery carried out for other primary reasons, if the lesion is causing epilepsy, and even if the operation influences the epilepsy, such operations are not generally included in epilepsy surgery statistics. The distinction though is not always clear-cut and the control of epilepsy can be an important additional consideration in the decision to undertake surgery. The term epilepsy surgery also implies a particular mindset and a specific approach to pre-surgical assessment which is discussed further below.

There are five main types of surgical approach:

1 Focal resection for hippocampal sclerosis and other lesions in the mesial temporal lobe;

2 Focal resections for other overt lesions (lesionectomies) in temporal neocortex or other cortical areas;

3 Non-lesional focal resections (where there is no lesion on imaging, but epileptic tissue is localized by functional methods and/or on clinical grounds);

4 Hemispherectomy, hemispherotomy and other multi-lobar resections;

5 Functional procedures—multiple subpial transection, corpus callosectomy, focal ablation, focal stimulation, vagal nerve stimulation.

The frequency of these operations in contemporary UK surgical practice is shown in Table 5.1.

Table 5.1 The approximate frequency of different forms of epilepsy surgery in modern surgical practice in the UK.

Focal resections for hippocampal sclerosis (e.g. temporal

65%

lobectomy, amygdalohippocampectomy)

Focal resections for other lesions

20%

Non-lesional focal resections

5%

Hemispherectomy, hemispherotomy and multi-lobar resections

5%

Functional procedures (e.g. corpus callosectomy, multiple

5%

subpial transection, vagal nerve stimulation)

Table 5.2 Aims of pre-surgical assessment for epilepsy surgery.

To confirm that the patient has epilepsy, and that the seizures are medically intractable To define the outcome goals of the chosen surgical procedure (e.g. seizure freedom [usually], 50% reduction in seizures) and estimate the chances of attaining this successful outcome To define the likely gains in terms of quality of life if surgery is carried out

To determine the risks of carrying out the surgical procedure—for instance in terms of mortality, neurological morbidity, psychological and social effects; also the risks of not operating To determine that the person is medically fit for surgery To counsel the patient appropriately about the outcome and risks

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