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The State of Surgical Therapy in Epilepsy

Posted Aug 24 2008 1:49pm
ANNOUNCER: Epilepsy affects approximately 2.5 million people in the United States, of which an estimated 300,000 are children under the age of 14. Although most children are able to achieve seizure control through the use of anti-convulsant medication, some can develop what's known as refractory or medication-resistant epilepsy. These children are unable to gain seizure control through the use of medication and must look to alternative treatments. One such alternative is brain surgery.

Although the risks and benefits of any surgical procedure need to be discussed thoroughly, this is especially true when it comes to pediatric brain surgery.

HOWARD WEINER, MD: The evaluation procedure for a child being considered for epilepsy surgery is very intense. All of the information, based on the imaging, the MRI scans, the functional imaging, such as PET scanning, SPECT scanning, MEG, are all considered. The clinical features and the EEG data are all put together, are discussed at a comprehensive conference, and a surgical plan is derived for that particular child.

After that's done, we sit down with the family, and we discuss the potential risks and benefits, what we think will be expected with this surgical approach, and the family really makes a decision about whether they want to go ahead.

ANNOUNCER: If an agreement is reached that surgery will be beneficial to the child, there are a variety of surgical techniques currently being performed.

HOWARD WEINER, MD: The traditional approaches, brain surgery or craniotomy, where the brain is actually removed, the seizure focus is identified using a variety of techniques, and if this can be done safely, this area of seizure focus is removed safely.

There are also techniques that involve neurostimulation, most commonly known as vagal nerve stimulation, which is a device that is implanted around the vagus nerve in the neck, attached to a generator, and delivers a certain current to the vagal nerve, which has a broad connectivity with the rest of the brain. And that has an ability to control seizures as well.

And there's a procedure called corpus callosotomy, which is done in the center of the head where the corpus callosum, a fiber bundle that connects the right and the left side of the brain is severed and that is done to prevent the rapid spread of seizure activity and to really help with these drop attacks. So that's also done more or less as a palliative procedure in children with this type of epilepsy.

ANNOUNCER: Pediatric brain surgery for epilepsy is most effective in children who fit three main criteria.

HOWARD WEINER, MD: The best candidates for pediatric epilepsy surgery are children who are: number one, having seizures that are not controlled by medication; number two, are having problems with their development that is thought to be related to the refractory seizures, that is, they're not developing their milestones like language or motor milestones and they're not able to participate fully in school or in social situations; and they have a comprehensive evaluation, including imaging such as MRI scan of the brain and EEG, electroencephalogram, which shows a focal abnormality that can be removed surgically.

ANNOUNCER: As with any surgery, safety is a major concern.

HOWARD WEINER, MD: Epilepsy surgery for children is very safe in 2005. Overall, if you look at the numbers, the chance of a very adverse complication from the surgery is exceedingly low. The risk is not zero, and we sit down with every family before we consider going down this road and have a very lengthy discussion about the expected benefits, the potential risks, the potential complications, so that everyone is well-aware of what we're getting into. And, obviously, we would only consider this type of approach if we know that the benefits far outweigh the risks, and most often it does.

ANNOUNCER: One of the main reasons that epileptic brain surgery is being used more and more is its high degree of effectiveness.

HOWARD WEINER, MD: Surgery for children with refractory epilepsy is very effective, and it really depends on the variety of characteristics that the child brings to the table. For example, if there's a very discrete focus in the brain that we can localize easily on MRI scan or other imaging modalities, and that abnormality correlates with the EEG, which is the electroencephalogram that is used to detect seizure activity. If that's the case, then the success rate of removing that focus is exceedingly high, 90 percent or above, for control of the seizures.

The opposite end of the spectrum is when there's nothing on the MRI scan and the electrical abnormality that is detected on EEG is very diffuse, and then we have to be very careful and limited in terms of what we can do. So there's a whole spectrum.

I would say that the success rate for all comers is: about two-thirds of children, in our experience, are rendered seizure-free from epilepsy surgery.

ANNOUNCER: Surgical therapy for children with epilepsy is an evolving field, and physicians, researchers, and surgeons are constantly looking for new ways to use surgical methods to help children with epilepsy.

HOWARD WEINER, MD: Surgical therapy for children with epilepsy has evolved over the years in the sense that it has become much more safe and much more effective. I think, previously, there was this sense that this was extremely dangerous, that it was aggressive, it was invasive. And I think many centers around the world have demonstrated that this is safe in carefully selected children. So I think there have been tremendous advances and we've only touched the tip of the iceberg in terms of children who might benefit from this.

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