New treatments are:
- Responsive Neuro-Stimulation. This technology, approved by the FDA in 2013, greatly expands the horizon for patients with medically intractable epilepsy localized in brain regions not amenable to surgical resection
- In 2012, the capability to perform Ictal-Spect was added as a routine option for the pre-surgical workup of the most complex patients. In this nuclear medicine study, a highly coordinated effort is required to obtain the imaging study after a radioisotope is injected during a seizure. This represents a very important new tool for the care of our patients.
- A young man with a hypothalamic hamartoma causing intractable epilepsy and behavioral disturbances was treated with the VISUALASE Stereotactic Laser Thermal Ablation method. This method allowed the patient to be treated in a minimally invasive way, avoiding a high-risk open surgical procedure and a long hospitalization and rehabilitation course, with significant cost savings. The surgery represents the first such case treated in the Los Angeles area.
In addition to these new options, the USC Comprehensive Epilepsy Center offers a wide range of treatments:
Medications are the leading treatment for epilepsy. Our epileptologists are expert in medication management and have special interests in the development of new medications. The goals of treatment are to provide current medication information and tailor your medication regime specifically to your needs.
People with epilepsy are often treated solely with medications called anti-epileptic drugs (AED).
There are numerous approved AEDs and experimental medications available. The medical management of people with epilepsy involves finding the most suitable medications to optimize daily life by controlling seizures.
- Medications do not cure epilepsy.
The goal of the physician is to work with you to maximize the beneficial effects of AEDs and minimize any potential negative side effects.
Deciding the most appropriate AED treatment depends on the type of epilepsy diagnosed. Medications are selected based on this information so it is vital that an accurate diagnosis is established in order to successfully manage seizures.
Determining an accurate diagnosis requires careful and expert interpretation of EEG findings along with details of the types of seizures experienced. Often people with epilepsy will need to take more than one AED to control their seizures. Regular visits to a physician are required for blood analysis and evaluation of medication effectiveness.
Epilepsy surgery has the most success in treating those with seizure activity originating from the temporal lobe. This is also the most common type of epilepsy diagnosed.
Establishing whether the type of epilepsy suffered can be treated surgically requires many interventions and can be a lengthy process. The most important factors in determining whether surgery is a possible treatment are:
- identifying the area(s) of the brain responsible for seizures and
- verifying if the identified area can be surgically treated without affecting functions of the brain
Confirming the suitability of surgery sometimes requires more than routine diagnostic procedures. More complex procedures such as a Wada test and intracranial EEG monitoring may be necessary.
It is important to know that the purpose of such testing is to ensure that the best possible outcomes are achieved. The goal of surgery is to reduce or eliminate seizure occurrence while preserving brain functions.
Assessment of surgical candidacy will start with the epileptologist who will require recent radiological brain images along with EEG data. Radiological imaging such as an MRI allows us to visualize the brain and its structures, while EEG data can show us the electrical activity of the brain and seizures in progress through video EEG monitoring. Other diagnostic tests, such as PET scans, also may be required. All of these tests are completed in an effort to establish exactly what areas of the brain are involved with seizures. Radiological and EEG data can provide a lot of information about the brain and seizure activity, but sometimes more information is required.
The brain is the most important and complex organ controlling all physical and mental functions. It is therefore very important steps are taken to ensure functions, such as speech and memory are preserved when considering brain surgery.
To obtain more detailed information about brain functions, the epileptologist may request a neuropsychological evaluation and/or a Wada test. These tests can reveal vital information about the areas of the brain responsible for speech, memory, understanding and other important functions. Knowing this detailed information helps to minimize/eliminate the risks of brain impairment from surgery.
If these procedures still do not provide all the details required by the epileptologist and the neurosurgeon, then intracranial EEG monitoring will be required. This is a surgical procedure which involves electrodes being placed in and on the brain surface to precisely map epileptic activity.
Once established, surgery is an option to treat epilepsy and your neurosurgeon will discuss the type of surgery most suitable. If seizures are not controlled with available treatments, a neurologist will diagnose this as intractable or refractory epilepsy. People with this type of epilepsy have often exhausted all available treatments, and surgery may be the only treatment option available to them.
Brain surgery may seem an extreme form of epilepsy treatment but it has proven to be successful in eliminating or reducing seizures and medication requirements in many people. As with all therapies for epilepsy the goals are to:
- stop the disease from progressing and causing more harm
- reduce or eliminate seizures and therefore improve the quality of life
- reduce or eliminate the need for medications
All surgical procedures come with risks. However, the evolution of modern medicine and sciences has made surgical procedures safer than ever before.
If surgery is an option, it is important you know as much about the procedure as possible and choose the right doctor to take care of you. For example:
- Ask the doctor if he/she is board certified. This demonstrates a high level of expertise in their chosen specialty.
- Ask how often the surgeon performs the type of surgery you are undertaking. Having a surgeon who performs these procedures on a regular basis shows familiarity and experience.
- Ask about the success rates and survival rates. It is important to know how successful these procedures are so that the benefits can be weighed against the risks.
- Ask to speak to people who have had this procedure. Your doctor should be able to put you in touch with past patients who want to share their experiences.
In order to be able to access the brain, the surgeon must first perform a craniotomy. This requires creating an opening in the skull. Under anesthesia, an incision is made into the scalp and skin and muscle are lifted off the bone. Then, using special surgical equipment, a piece of bone is removed. This is known as a bone flap. Once this is done, the surgeon carefully pulls back the membrane that covers the brain (dura). Surgery is then performed using microscopes and special equipment. Once surgery is complete the bone flap is carefully put back into place using wires, plates and screws. Skin and muscle are sutured. The wires used are MRI-compatible and need never be removed.
This is performed by a team of neurosurgeons who removes the area of the brain responsible for seizures. The area of the brain to be resected is determined during the pre-surgical work up (see surgical evaluation).
When it has been determined this area of the brain is safe to remove (not responsible for important functions), resective surgery can take place. The goal of the physicians is to reduce or eliminate seizures while conserving brain capability.
The most common type of epilepsy surgery is a resective surgery known as a temporal lobectomy. This is due to the fact that about 80 percent of seizures causing epilepsy will originate from the temporal lobe.
If seizures have been found to originate from a single focus in the temporal lobe and its structures, a temporal lobectomy is performed. This procedure involves removing the area of the temporal lobe causing seizures.
A customized version of this surgery is performed based upon the type and location of brain tissue that is to be removed. This surgery is known as a tailored temporal lobe resection or selective amygdalohippocampectomy. Surgery usually takes four to six hours and the total hospital stay is often not more than five days. Success rates for this procedure are high, with an estimated 75 percent of patients undergoing this surgery becoming seizure-free.
If seizures originate from multiple focal points in one hemisphere or seizures are restricted to one hemisphere, then a hemispherectomy may be indicated to treat epilepsy.
This surgery involves removing one hemisphere (half) of the brain that is already damaged, most likely by the effects of multiple seizures.
This type of surgery may be called an anatomical or functional hemispherectomy. In an anatomical hemispherectomy, a hemisphere is removed totally while in some cases, some brain is left in place but its connections to other brain areas are cut.
This surgery is reserved for the most severe cases of epilepsy and is typically performed on children as they recover better from this type of surgery. Most children who are candidates for hemispherectomy usually have significant impairments caused by their epilepsy.
Surgery usually takes four to six hours and the total hospital stay is often no more than a week. Post-operative occupational and physical therapy will be required. Seizures are eliminated in 70 to 85 percent of patients and reduced by 80 percent in 10 to 20 percent of patients.
If seizures occur from many focal points of the brain or no focal point can be found, a corpus callostomy may be indicated to treat epilepsy.
This type of surgery involves cutting the nerve fibers called the corpus callosum. These fibers are what connect the two hemispheres together. The purpose of cutting them is to stop the spread of seizures from one hemisphere to another with the hope of reducing the frequency of seizures.
This type of surgery often is performed on children who suffer from drop attacks or atonic seizures. People suffering from generalized tonic clonic seizures and those with massive jerky movements may also benefit from this type of surgery.
Surgery usually takes four to six hours and the total hospital stay is often no more than a week.
Drop attack seizures may be eliminated in 70 percent of patients. Other types of seizures may also be reduced by 50 percent.
To determine the value of surgical procedures, their outcomes must be known.
A surgical procedure is analyzed to determine the risks of surgery against its outcomes. The most relevant surgical outcome information pertaining to epilepsy surgery is the same as all other types of epilepsy treatment. The goals of all treatments are to:
- Reduce or eliminate seizures
- Reduce or eliminate the need for medication
- Stop the progression of the disease
The VNS is a device, which in conjunction with medications, is used to help reduce and sometimes eliminate seizure activity. It also is beneficial when surgery is not an option.
The device is similar to a cardiac pacemaker. It is implanted over the chest wall and an electrode is attached to the vagus nerve. This electrode stimulates the vagus nerve which communicates with the brain and is designed to reduce seizure frequency. Stimulation occurs regularly and can also be initiated. If a seizure is anticipated, a magnet is placed over the device in an effort to reduce the intensity or eliminate the seizure. It can also be used the same way during a seizure. Additionally, it may also help reduce the amount of anti-epileptic medications needed.
A neurosurgeon will implant the device in the operating room. This is a straightforward procedure which usually only requires a stay of one day in the hospital.
Working closely with the creators of the VNS, we can offer this device as an adjunct therapy in treating epilepsy.
The ketogenic diet was discovered in the 1920s and was a common treatment for epilepsy until anti-epileptic drugs became available. These then became the treatment of choice for epilepsy, and the ketogenic diet for the most part was forgotten. It has reemerged in recent years and currently is being offered as a therapy, mostly to children with refractory epilepsy.
It is a diet rich in fats and low in sugars and proteins. The body burns fats for energy which creates ketones. Its mechanisms are not fully understood but it is thought that ketones reduce seizure frequency by reducing irritation to the central nervous system. The ketogenic diet has shown the most favorable results in children with certain epilepsy syndromes, and studies have found that medication requirements also were reduced.
Due to the types of foods that need to be eaten in this diet, such as heavy fats and the lack of vitamins, expert monitoring from a physician and a dietitian is necessary.
The modified Atkins diet is similar to the ketogenic diet in that the consumption of foods high in fats is required. It is more user-friendly than the ketogenic diet as it does not restrict fluids and calories, and has been found to reduce seizures in children and adults as well as medication requirements.
Just like the ketogenic diet, a physician and dietician need to be involved as there are side effects to the diet.