Epilepsy Surgery in Delhi, India

Epilepsy surgery is a neurosurgical procedure to treat epilepsy by reducing or stopping seizuresin individuals whose seizures cannot be controlled with medications. An evaluation for epilepsy surgery is appropriate for anyone with seizures that may be focal in origin, that are continuing to occur despite treatment with antiepileptic drugs (AEDs), and whose quality of life is significantly impaired by epilepsy. Although the exact number of medication trials must be individualized, initial consideration is reasonable after 2 monotherapy trials with first line AEDs, and possibly one trial with duo-therapy (combination of 2 AEDs). The most common location of seizure onset in adults is the temporal lobe, especially the medial temporal lobe (hippocampus). This is also the seizure location most amenable to surgical cure. The goal of epilepsy surgery is to remove or alter the part of the brain that is causing the seizures, preventing them from spreading or recurring. Epilepsy surgery can significantly improve daily functioning and independence, offering relief to those whose epilepsy is severely affecting their lives. At Max Hospitals, epilepsy surgery is considered after a comprehensive assessment by a team of specialists, ensuring that it is the right choice for each individual.

Epilepsy surgery can be divided based on the goals of the operation into palliative and curative procedures. Examples of curative procedures include lesional resection, lobectomy, corticectomy, and some cases of hemispheric surgery and multiple subpial transections. There is preliminary evidence that gamma knife radiosurgery may have a role in the treatment of temporal lobe epilepsy and for cavernous malformations associated with epilepsy. The primary goal of a curative surgery is for the patient to be able to lead a normal life, preferably off of all antiepileptic medications. There is gathering evidence that early surgical intervention is favorable for a variety of reasons. Becoming seizure free at a younger age may lessen the cognitive, behavioral, and psychosocial problems experienced by epilepsy patients, potentially improving societal integration. Additionally, because continued seizures may result in progressive neurologic damage over time, surgery has the potential to be neuroprotective in comparison to continued medically refractory seizures. If a hemispheric procedure is required or if "eloquent" areas of the brain are within the epileptogenic zone, the potential for recovery of language and sensorimotor functions is better when patients are younger.

By definition, palliative procedures only very rarely result in cessation of seizures. These surgeries may prevent the occurrence of a particularly morbid type of seizure such as drop attacks or lessen the frequency or severity of seizures. Palliation may be a desirable result in patients with seizure related injuries or with a predominance of one seizure type that can be eliminated with surgery. Examples of palliative surgery include some cases of hemispheric surgery, multiple subpial transections, disconnection procedures including corpus callosotomy.

At Max Hospitals, a variety of surgical options are available for patients who do not respond to medication. The types of surgery performed are carefully chosen based on the location and type of seizures. These include, but are not limited to:

Resective Surgery

Resective surgery is often the first choice for patients with seizures that originate in a specific area of the brain. The surgery involves removing the tissue where seizures begin. By removing this tissue, the goal is to stop or significantly reduce the frequency of seizures. This procedure is most effective for patients with focal seizures that are confined to one region of the brain.

Laser Ablation Surgery

Laser ablation is a minimally invasive alternative to traditional surgery. A thin laser fibre is inserted through a small incision into the brain. Using advanced imaging, the surgeon directs the laser to the area causing seizures and destroys the tissue. This technique is highly precise and often leads to a faster recovery compared to open surgery.

Corpus Callosotomy

This surgery is performed when seizures affect both sides of the brain. The procedure involves cutting the corpus callosum, the structure that connects the two halves of the brain. By severing this connection, it prevents seizures from spreading from one hemisphere to the other. This procedure is typically used for patients with generalized seizures that cannot be controlled with other treatments.

Vagus Nerve Stimulation

Vagus nerve stimulation involves implanting a device under the skin near the collarbone, with a wire connected to the vagus nerve in the neck. The device sends regular electrical pulses to the nerve, which in turn helps regulate abnormal brain activity. This treatment is often used for patients who are not candidates for traditional brain surgery.

Responsive Neurostimulation

Responsive neurostimulation involves the implantation of a small device within the brain that monitors electrical activity. When abnormal brain waves are detected, the device sends electrical pulses to disrupt the seizure activity before it can lead to a full-blown seizure. This system can be adjusted to fit each patient’s seizure patterns and is especially useful for patients with focal seizures that are difficult to treat.

Deep Brain Stimulation

DBS surgery involves placing electrodes in certain areas of the brain. The electrodes send electrical impulses to control abnormal brain activity and reduce seizures. It is often used for patients whose seizures are not controlled by other methods.

Epilepsy surgery is typically considered when seizures cannot be effectively controlled with medications or other treatments. However, it is not the first option and is usually explored after all other options have been exhausted. Surgery is recommended under the following circumstances:

• Seizures are not controlled by medications: When multiple medications fail to stop seizures or significantly reduce their frequency, surgery may be considered as the next step.
• Seizures originate from a specific area of the brain: If the seizures are localized to a specific area of the brain, surgery can be an effective option to remove or treat that specific region.
• Seizures are severe and impact daily life: When seizures are frequent, severe, or cause major disruptions in daily activities or lead to physical or cognitive impairments, surgery may be necessary to prevent further complications.
• Other treatment options are ineffective: If other treatments, such as Vagus Nerve Stimulation (VNS), fail to control seizures, surgery may be considered.
• Seizures are not widespread in the brain: Surgery is generally only an option if seizures are confined to one area of the brain. If the seizures affect both sides, surgery may not be effective.
• Comprehensive testing supports surgery: In-depth testing, including brain scans and EEG, is conducted to pinpoint the source of the seizures. Surgery is considered when the results show that a specific part of the brain is responsible and can be safely treated with surgery.

Specialists at Max Hospital work closely with each patient to assess their individual case and determine the most appropriate treatment.

Before undergoing epilepsy surgery, several important steps ensure the patient is well-prepared for the procedure.

Comprehensive Evaluation

A thorough assessment is the first step. This includes reviewing the patient’s medical history, the frequency and type of seizures, and how well medications have worked. Tests like EEG, MRI, and PET scans will help locate the source of the seizures in the brain.

Consultation with a Multidisciplinary Team

Epilepsy surgery involves a team of specialists, including neurologists and neurosurgeons. They will discuss the benefits and risks of surgery and determine if it's the best option for the patient. This ensures a well-rounded approach to treatment.

Pre-Surgery Planning and Tests

Video/EEG monitoring of typical events with scalp EEG

This is the cornerstone of the epilepsy surgery evaluation. Continuous EEG with synchronized video monitoring is performed in an epilepsy monitoring unit until the patient has their typical spells. Medication withdrawal is often necessary to help elicit spells more quickly.

Imaging

• MRI

The presence of a focal epileptogenic lesion on MRI increases the chance of surgical cure significantly. 

In patients with temporal lobe epilepsy (TLE), special views of the medial temporal lobes with thin oblique coronal cuts often reveal hippocampal atrophy and increased signal. These findings strongly correlate with pathological evidence of hippocampal sclerosis (neuronal loss and gliosis, also called mesial temporal sclerosis, or MTS) and with seizure freedom after temporal lobectomy (approximately 80% chance). 

• PET

Positron emission tomography (PET) utilizes an injection of radio-labeled glucose (18FDG) to measure brain metabolism. Interictal PET usually shows hypometabolism in the seizure focus, especially in TLE. 

• SPECT

Single photon emission computed tomography (SPECT) utilises injection of a radio-labeled tracer of blood flow that binds on first-pass through the brain; thus, it is a snapshot of circulation at the time of injection. The tracer is stable for several hours, allowing delayed imaging. The most useful study for presurgical evaluation is an ictal SPECT, in which the injection is performed (as early as possible) during a seizure and the patient is scanned within a few hours. Ictal studies usually reveal increased blood flow at the site of seizure onset.

• Magnetoencephalography (MEG)

MEG is a relatively new diagnostic technique, primarily used in research settings. MEG is similar to EEG, but it detects magnetic rather than electric signals from the brain.

• Functional MRI (fMRI)

fMRI can be used to map motor, sensory and language functions noninvasively, and is most commonly used as part of surgical planning.

Neuropsychological testing

Formal neuropsychological testing is important as a pre-operative baseline, as a predictor of possible cognitive loss with surgery, and as an additional aid for localization.

Video/EEG monitoring with intracranial EEG

If the seizure focus cannot be adequately localized and safely resected based on the above studies, recording seizures with intracranial EEG may be necessary. Intracranial electrodes are inserted neurosurgical, and include subdural (or epidural, though less common) strips or grids of electrodes, or parenchymal "depth" electrodes.

Epilepsy surgery is carefully planned and performed to help control seizures. Here’s what happens during the procedure:

• Anaesthesia: The patient is given anaesthesia to ensure they are completely asleep and feel no pain during the surgery. In some cases, the patient might stay awake for certain parts of the procedure if needed.
• Reaching the brain: The surgeon makes a small cut on the scalp and removes a small piece of the skull to reach the brain. Special tools and imaging are used to find the exact area causing the seizures.
• Performing the surgery: The type of surgery depends on the patient’s condition. It might involve removing a small part of brain tissue, cutting certain brain connections, or placing devices like stimulators to control seizures.
• Monitoring brain function: During surgery, the brain’s activity is often monitored to ensure the procedure is accurate and does not affect important brain functions.
• Closing the incision: Once the surgery is done, the surgeon places the skull piece back and closes the cut on the scalp. The patient is then moved to a recovery area for observation.

At Max Hospitals, epilepsy surgeries are performed with great precision to ensure accuracy and safety during the procedure, eventually helping improve the lives of patients with epilepsy.

Recovery after epilepsy surgery involves careful monitoring and follow-up care. Here’s what typically happens:

Hospital Stay

After the surgery, patients are taken to a recovery room for close observation. Most patients stay in the hospital for a few days to ensure they are stable and healing well. During this time, doctors monitor for any signs of complications, such as swelling or infection.

Immediate Recovery

Mild pain, swelling, or discomfort around the surgical site is common and managed with medications. Patients may feel tired or groggy for a few days as the body adjusts.

Follow-Up Appointments

Regular follow-ups are essential after epilepsy surgery. These appointments help doctors check healing progress and monitor seizure activity. Imaging tests, like MRIs, may be done to ensure the brain is recovering properly.

Seizure Management

Some patients experience fewer or no seizures after surgery, but others may still need medications or additional therapies. Adjustments to seizure management plans are made based on how the patient responds post-surgery.

At Max Hospitals, the focus is on comprehensive post-surgery care to support recovery and help patients achieve the best possible results.

Risks and Complications

Epilepsy surgery is considered safe and effective, but like all surgical procedures, it carries some risks and potential complications. These may include:

• Infection: A minor risk of infection exists at the surgical site, which is usually treated with antibiotics if it occurs.
• Bleeding: Although rare, some bleeding can happen during or after surgery. Advanced surgical techniques help minimize this risk.
• Swelling or Fluid Build-Up: Temporary swelling or fluid accumulation around the brain is possible but is closely monitored and managed by the medical team.
• Neurological Changes: Depending on the area of the brain treated, there may be temporary or permanent changes in speech, memory, or motor functions.
• Seizures: Surgery often reduces or stops seizures, but in some cases, they may still occur post-surgery, requiring further adjustments in treatment.
• Anesthesia Risks: Reactions to anesthesia, such as breathing issues or allergic responses, can occur, though these are rare and usually well-managed
• Stroke: The risk of stroke is minimal but can result in weakness or difficulty with certain functions if it occurs.
• Emotional or Psychological Effects: Patients may experience emotional challenges, such as anxiety or depression, particularly during the recovery process

At Max Hospitals, a team of specialists closely monitor the pre and post surgery phases to reduce risks and ensure patients receive the best care.

1. How long does it take to recover from epilepsy surgery?

Recovery time varies depending on the individual and the type of surgery performed. Generally, patients may stay in the hospital for a few days and can expect to resume light activities within a few weeks. Full recovery may take several months.

2. Will epilepsy surgery completely stop my seizures?

Although many patients experience a significant reduction in seizures, complete seizure freedom is not guaranteed. The success of the surgery depends on various factors, including the type of epilepsy and the area of the brain affected.

3. Can I drive after epilepsy surgery?

Driving restrictions may be in place following surgery, especially if seizures persist. A doctor will assess the patient's condition and provide guidance on when it is safe to resume driving.

4. Will I need to continue taking medication after surgery?

Some patients may still need medications after surgery, though the dosage or type of medication may change. The NEUROLOGY team will adjust medications based on seizure control.

5. Is epilepsy surgery a one-time treatment?

For many patients, epilepsy surgery provides long-term seizure control. However, some may require additional treatments, including further surgeries, medications, or therapy, depending on their individual condition.

6. Can epilepsy surgery affect my cognitive functions?

In rare cases, surgery may impact cognitive functions like memory, language, or motor skills, depending on the area of the brain affected. The surgical team carefully monitors these risks and aims to minimize them.

7. How do I know if I am a candidate for epilepsy surgery?

Candidates for epilepsy surgery typically have seizures that are not controlled by medication and have been thoroughly evaluated by a team of neurologists and neurosurgeons. A series of tests and assessments will determine if surgery is the best treatment option.

8. What is the success rate of epilepsy surgery?

The success rate of epilepsy surgery varies depending on factors like the type of epilepsy and the location of the seizure focus. On average, many patients experience a significant reduction in seizures or even become seizure-free after surgery.

9. What are the risks of not having epilepsy surgery?

Without surgery, uncontrolled seizures can lead to health risks, including injury, depression, and a reduced quality of life. In some cases, not having surgery may limit options for improving seizure control.

10. Can I have epilepsy surgery if I have other medical conditions?

Having other medical conditions does not automatically disqualify someone from epilepsy surgery. However, the surgical team will evaluate the patient's overall health to determine if surgery is safe and appropriate.

Reviewed by Dr. Vivek Kumar, Principal Director - Neurosciences, Neurology on 16 Jan 2025.