Types, Procedure & Purpose Of Epilepsy Surgery In India

Epilepsy surgery – Overview

Medications can manage seizures in the majority of individuals with epilepsy; however, they do not work for everyone. About 30% of those taking the epilepsy drugs are unable to withstand their side effects.

Epilepsy surgery is not the primary line of treatment; however, it may be considered if at least two different anti-seizure medications have been unsuccessful in controlling seizures. When seizures often arise in a single location inside the brain, epilepsy surgery is perhaps the most effective.

Epilepsy surgery is a type of brain surgery that is used to reduce or stop the number and/or severity of seizures by removing the region of the brain from where the seizures arise. Seizures are bursts of uncontrollable electrical activity between nerve cells in your brain that can cause changes in:

• Muscle control (muscles may jerk or twitch)
• Awareness
• Emotions
• Sensations
• Behaviour

Several tests may be required prior to surgery to determine if epilepsy surgery is the right alternative and what type of procedure needs to be performed.

Why is epilepsy surgery done?

When medications fail to control seizures, epilepsy surgery might be an option. This is medically refractory epilepsy, also known as drug-resistant epilepsy. Epilepsy surgery is performed to either stop or reduce the severity of seizures. Surgery is also performed to reduce seizure-related deaths, the usage of anti-seizure medications, and the potential side effects of the medications.

Uncontrolled epilepsy can lead to a variety of health risks and complications, including:

• Physical injuries sustained during a seizure
• Anxiety and depression
• Developmental delays in children
• If the seizure occurs while bathing or swimming, the person may drown
• Worsening thinking and memory skills
• A rare complication of epilepsy is sudden death

Who is a candidate for epilepsy surgery?

Surgery can only be an option if and only if:

• Your doctor can pinpoint the exact location inside the brain from which the seizures begin, known as the seizure focus.
• The removed area does not control any critical functions, including sensation, language, or movement.
• If your seizures are caused by a non-epileptic condition, such as a brain tumour or an arteriovenous malformation.

If you meet these requirements, it works best when:

• Your seizures are debilitating, frequent, and severe.
• Your seizures are not controlled by medication.

Severe side effects of any seizure medication are reducing your overall quality of life. People with other serious health issues, such as heart disease or cancer, are typically not eligible for this treatment.

Are there any risks associated with epilepsy surgery?

Your doctor will go over the advantages and disadvantages with you before the surgery.
Some of the risks include:

• Infection and bleeding
• Allergic reaction to the anaesthesia
• Slow healing at the site of surgery
• Tissue damage in the adjacent area of the operation site (brain)
• Seizure recurrence

Additionally, the surgery can worsen your existing problems or cause new ones due to the way your brain functions. You may experience loss of speech, vision, memory, or movement.

This is the reason healthcare professionals conduct brain mapping and extensive pre-surgery testing to pinpoint the source of the seizures. Your surgical team will do everything possible to ensure that your planned surgical procedure avoids these critical areas.

Epilepsy surgery types

Epileptic seizures are caused by abnormal activity of cells in the brain known as neurons. The type of surgery you may get is based on the kind of seizures you are experiencing, where they begin in your brain, and your age.

Surgical resection

In surgical resection surgery, a neurosurgeon will remove a particular segment of your brain during the surgery. Your neurosurgeon may also remove brain tissue close to the site of the seizures. There are various types of resections, such as:

• Lobectomy: A lobectomy is a surgical procedure that involves the removal of a lobe, a part of the brain. The brain is divided into four lobes: temporal (above the ear), frontal (front of the head), parietal (just above the temporal segment), and occipital (back of the head). A lobectomy involves your neurosurgeon removing the lobe where the seizures begin. One of the most commonly used types of epilepsy surgery is a temporal lobectomy.
• Multilobar resection: This surgery includes the removal of all or parts of two or more of your brain’s lobes. This surgery is only considered if there are no vital functions in those lobe areas.
• Hemispherectomy: This surgery involves disconnecting or removing one-half of your brain. Disconnecting means severing the fibres that normally connect the right and left lobes of your brain. This surgery is usually reserved for seizures that are severe, uncontrollable, and debilitating. In such situations, the hemisphere being considered for removal has frequently sustained significant injury or damage, which  results in loss of feeling or paralysis.
• Lesionectomy: In this surgery, lesions that can cause seizures, such as cavernous haemangiomas, tumours, and arteriovenous malformations, are removed.

Surgical disconnection

The communication between the region of the brain causing the seizures and the residual normal brain tissue is severed during these surgeries.

• Corpus callosotomy: This surgery includes cutting the corpus callosum, which constitutes the main fibre bundle that connects your brain’s two halves (hemispheres). This surgery is performed when debilitating, severe seizures begin on one of your brain’s sides and spread to the other.
• Multiple subpial transections: In this surgery, several shallow cuts are made into a small section of brain tissue. The incisions prevent communication between seizure-producing nerve cells and other nerve cells (normal nerve cells). This surgery is an option when the region of your brain causing the seizures cannot be safely removed.

Stereotactic radiosurgery

This surgical procedure, which involves using 3D computerised imaging to accurately focus the beams of radiation on a target, destroys the nerve cells that are causing seizures.

Laser interstitial thermal therapy

This procedure is much less invasive compared to other open procedures. Your neurosurgeon will first drill a small opening in your skull, and an MRI scan will guide the small probe to the region of your brain in which the seizures initiate. The seizure site is targeted with focused laser energy. This energy is converted into heat energy, which destroys nerve cells at the seizure site. To protect nearby tissue from heat injury, a computer programme tracks its temperature. This surgery is chosen when the site of the seizure is confined to a small region.

Neuromodulation

These procedures entail implanting devices to enhance seizure control. There is no removal of brain tissue. These include:

• Vagus nerve stimulation: This device is used to place electrical lead wires around the vagus nerve (situated in your neck). The vagus nerve originates in the lower part of the brain and travels to the abdomen. A tiny pulse generator the size of a matchbox is implanted beneath your collarbone. The pulse generator sends mild electrical pulses to the brain on a regular basis in order to interrupt any abnormal bursts occurring during a seizure. This is an office procedure that is considered when two or more anti-epileptic medications have been tried but have failed to control seizures, as well as in people who are not candidates for other surgical procedures or when surgery has failed.
• Responsive neurostimulation surgery: This procedure entails inserting a device on or into the surface of brain tissue in the region where seizures begin. Whenever this device detects the beginning of a seizure, it transmits an electrical impulse that terminates the seizure. This device is approved for adults who have focal seizures (seizures confined to one area of your brain) and have failed to control the seizures with two or more anti-seizure medications.

What happens following epilepsy surgery?

After epilepsy surgery, you should expect swelling on the face and scalp and headaches. You will be given medications to alleviate these symptoms. Symptoms subside after a few weeks. The majority of patients have a one-day critical care stay followed by a 3–4-day hospital stay.

You will need to keep taking your anti-seizure medicine for a while after the surgery. The medications protect your brain while it heals and reduce your chances of experiencing seizures later on.

You will require ample rest as you gradually resume routine daily activities in four to six weeks. You should be able to resume your job or school within one to three months.
If you have not had any seizures for a year or so, your doctor may eventually decrease your drug doses and finally discontinue it.

Unless your critical functions (speech, memory, and movement) have been compromised, you will not require rehabilitation therapy.

 How should I weigh the risks against the advantages of epilepsy surgery?

The primary objective of epilepsy surgery is to reduce the frequency and severity of seizures or, ideally, to be seizure-free. This goal might or might not be achievable for you. Everyone gets different results.

Even if you are not completely seizure-free after surgery, you may benefit from:

• A lower anti-seizure medicine dosage or a reduction in the number of medicines you must take, both of which can decrease medication side effects.
• A decreased likelihood of life-threatening complications, including epilepsy-related sudden death or status epilepticus.
• If the surgery is successful, there is a reduced chance of depression and anxiety.
• A higher likelihood of returning to driving and work.

On the other hand, experiencing continued, uncontrolled seizures can be dangerous. If you are already taking anti-seizure medicine and the seizures are still not controlled, it is unlikely that adding more medicine will stop them (only 10% of the time).

Furthermore, the more medicines that are tried and failed, the lower your chances of seizure management. Other risks of uncontrolled seizures include memory loss and the loss of social connections over time if you avoid interacting with others.

Your epilepsy surgical team and you must decide whether surgery is a suitable solution for you. To determine whether you are a candidate for surgery, you will need to undergo extensive testing. If you are a candidate, inquire about speaking with other individuals who have had the surgery that has been recommended for you, and do not be hesitant to talk with a counsellor. If you qualify, only you can decide whether the advantages of epilepsy surgery are worth the risks.

Epilepsy surgery cost in India

The cost of an epilepsy operation in India varies depending on a number of factors, including the type of surgery, the hospital, and the city. On average, the cost of epilepsy surgery in India starts at 2 lakh Indian rupees; however, some high-end hospitals in major cities such as Delhi, Mumbai, and Bangalore may charge more. It is advisable that you check with the hospital and get an estimate of the total cost. They will be able to give you information on the costs of pre-operative tests, post-operative care, and any other associated expenses.

Takeaway
If you suffer from epilepsy and medicines have failed to manage it, epilepsy surgery could be an option. There are now numerous epilepsy surgeries available. The location of the seizures in your brain is important in determining which surgery is best for you. No one with epilepsy is the same.

If a surgical procedure is an option for you, your epilepsy team will provide you with all of the information you need to understand the procedure’s benefits and risks so you can make the most informed decision. Be honest and open with your treatment team, and never be hesitant to ask them questions. They are here to help you make your decision.
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