Surgery

Surgery for epilepsy is a method of seizure control. It is not designed to replace medications. Surgery for epilepsy is possible for some but not all patients whose control is inadequate. In carefully selected patients, surgery has a high chance of controlling seizures completely.

Your Neurologist will have suggested to you that perhaps surgery would help with your seizure control. This means that the area of focus for your epilepsy is probably located in an area of your brain that can be removed safely. This area is usually located in part of one of the temporal lobes which sit near the ears.

This type of epilepsy is sometimes called temporal lobe epilepsy and the type of seizures that can occur are called complex partial seizures.

Surgery is usually considered for people who have tried many antiepileptic medications and yet not gained the seizure control that they desire.

The operation and most of the procedures needed to determine whether you would benefit from surgery are done at The Queen Elizabeth Hospital and other large hospitals. These procedures are:-

• Electroencephalography (E.E.G.)
• Single Photon Emission Computerised Tomography (S.P.E.C.T.)
• Magnetic Resonance Imaging (M.R.I.)
• Continuous Video / E.E.G. Monitoring
• Wada Test
• Consultations with:
• Neurologist
• Epilepsy Nurse
• Neuropsychologist
• Neurosurgeon
• Neuropsychiatrist
• Social Worker

Brain Imaging:

No doubt you will have had several E.E.G.’s but be prepared to have more. An E.E.G. gives a surface indication of brain cell electrical activity and is one method of determining the source of seizure activity. S.P.E.C.T. and M.R.I. are more sensitive brain imaging studies that will indicate if changes in the brain structure has occurred. S.P.E.C.T. scans are done in the Nuclear Medicine Department of The Queen Elizabeth Hospital and M.R.I. is done at the Flinders Medical Centre.

Continuous Video / E.E.G. Monitoring:-

The purpose of continuous video/E.E.G. monitoring is to observe your seizures via a video camera and at the same time record your brain cell activity through the E.E.G. Continuous E.E.G. is generally painless and is similar to routine E.E.G. only the electrodes stay on your head for the time you are being monitored. During monitoring you will be required to stay in the monitoring room 24 hours a day. It may be necessary to reduce your antiepileptic drug dose(s) before and during admission to ensure that a seizure is observed. Seizures are recorded via a video camera mounted on the wall of the room.

During a complex partial seizure you will be given and injection into a blood vessel in your hand or arm. The solution given is ceretec, which is used to locate the area of the brain that is the focus for seizure activity. Following the injection you will be taken to the Nuclear Medicine Department for a special type of C.T. scan called a S.P.E.C.T. When the results of this scan are known you will be told whether surgery is likely to proceed. Sometimes more than one scan is needed and even then may not give the information the doctors are seeking.

During this admission you will be visited regularly by your Neurologist and other Medical Staff of the epilepsy program. Other personnel involved in the epilepsy program who will see you will be a Psychiatrist, Neuropsychologist and a Social Worker. The Psychiatrist will ensure that you are fully prepared for brain surgery and he/she will tell you what reactions you can expect after surgery.

The Neuropsychologist will assess your memory, thinking and personality, if this has not already been done. As you may be aware, epilepsy may affect memory and to what extent yours may be affected will be assessed. A Social Worker will make contact with you to establish if you need any assistance with financial matters, accommodation, travel, family matters or counselling. The Epilepsy Nurse will be available to assist you with all aspects of the surgical preparation to ensure that you are fully aware of what is happening to you.

WADA Test:

– (named after Dr Juhn Wada).

You will be admitted to hospital for this test, usually discharge is on the same day. The test is done to ensure that removing the area of the temporal lobe will not affect your memory or speech ability. This procedure involves the Radiologist inserting a tube into a blood vessel in your groin and gently passing it up into the main artery to one side of your brain. A sedative called amytal is then injected into the side of the brain which will put it to sleep. The Neuropsychologist will then ask you some simple questions, much the same as during the memory and cognitive function assessment. Following a short break, the procedure may be repeated on the other side.

The procedure is not painful but you may experience some drowsiness as well as some disturbance of thinking processes including speech. These effects will subside over some minutes. When all test results are available, a team meeting is held. Your case is discussed in detail and a recommendation to proceed or not with surgery is made. It may be necessary to see the surgeon prior to surgery to discuss what will happen, risks involved and to answer any final questions.

IF YOU FEEL AT ANY TIME DURING THESE PROCEDURES THAT YOU MAY NOT WISH TO PROCEED, SPEAK TO ANY MEMBER OF THE EPILEPSY PROGRAM AND MAKE CERTAIN THAT ANY WORRIES ARE OVERCOME BEFORE PROCEEDING.

Temporal Lobectomy:-

You will be admitted the day before surgery so you can be fully prepared for the operation. The anaesthetist will see you just prior to the operation. The operation may take 3-4 hours. The hair over the operation site is shaved and the incision is closed with stitches or clips. The incision is curved, shaped around the back of the ear approximately 10-15cm in length and will be completely covered when the hair regrows. Immediately after the operation you will spend about 48 hours in the Intensive Care Unit. Expect to feel very drowsy, have a headache and some facial swelling for a few days but, each day these symptoms will become less. When you first start getting out of bed you will feel unsteady and dizzy on your feet but these feelings will gradually subside. The stitches or clips are removed in about 7 days and you will be discharged from hospital 7-10 days after the day of the operation.

After The Operation:-

Following discharge from hospital, you will need to rest. Listen to what your body is telling you and rest when you feel tired. Expect to feel tired and not have your usual level of energy for about 3 months or more.

Anti-epileptic medications are continued after the operation, frequently the same type and dose as previously. Medications are continued for at least 2 years and more likely for longer. It has been reported recently that 70% of people remain seizure free following temporal lobe surgery. Less than 5% of people experience complications. These include:-

• Loss of small areas of perimeter vision – common
• Anxiety and depression – temporary
• Speech difficulties – rare
• Memory deterioration – rare
• Seizures/changes in seizures – rare
• Surgical/anaesthetic mishaps – rare
• Stroke – rare
• Risk of failure – rare

You may return to work when you feel able, but allow at least 6 weeks to fully recover your strength. If you are planning a pregnancy following the operation, discuss this with your Neurologist.

If you remain seizure free, you may be able to consider obtaining or regaining your drivers license.
Alternatives:-

1. Acceptance of current situation and continuation of present medications.
2. Participation in new drug trials if available and you are suitable. However the introduction of new drugs rarely result in complete control of seizures.

For your own record, you may like to note down the dates for the following:-
PROCEDURE – DATE – COMMENT

• M.R.I.
• CT Scan
• Video/E.E.G. Monitoring
• Wada Test
• Operation
• Discharge from Hospital
• Return to/Gain Employment
• Driving Licence