Learning disability (a full-scale IQ < 70) is a complicating factor when considering surgical therapy, for a number of reasons. First, it often indicates widespread cerebral dysfunction and resective surgery is less likely to control seizures even if a single lesion is demonstrable. Furthermore, in multiply handicapped persons, epilepsy may not be the most important aspect of disability, and control of seizures will not necessarily lead to major gains in quality of life. Finally, 'cerebral reserve' may be lower in persons with learning disability. On the other hand, many patients with learning disability are severely handicapped by severe epilepsy and have the potential for great benefit from surgery. Expert evaluation of these issues is necessary for all affected individuals, and the risk-benefit equation needs careful formulation and discussion with the patient and carers. The ethical issues surrounding informed consent are extremely important, and can be difficult.
Surgery is generally also contra-indicated in individuals who show severely dysfunctional behaviour. It should not be contemplated if it is likely that the patient will not be able to tolerate the intensive investigation or hospitalization required for epilepsy surgery, nor make informed and considered judgements about the potential risks and benefits of epilepsy surgery, nor be able to exploit the opportunities afforded by successful surgery.
The presence of a chronic interictal psychosis is also generally a contra-indication to surgery, as the psychosis can worsen dramatically after surgery. Decisions about surgical treatment should not be made by severely depressed patients. Psychosis and depression may also prevent informed consent. Again, individual decisions in this situation require a detailed assessment by an experienced practitioner.
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