Language mapping is done during surgery while the patient is awake and interactive.  This is possible because the brain itself does not have pain receptors.

The patient is shown sequential pictures of common objects, while a region of the brain is electrically stimulated in one centimeter increments.

When the patient cannot successfully name objects during stimulation of a particular part of the brain, that brain area is concluded to be important for visual object naming.

The widely held belief is that visual object naming is primarily a function of the lateral [outermost] temporal lobe.

Mike actually had his first seizure earlier that year in his fourth period English Class. Lucky for him, his friend Rob stopped him from crashing to the floor.  Mike says, “They said it was a black out, no one even thought of epilepsy at that time.”

The year after that, he had a couple more seizures but when he started college the following year he began to average 4-5 seizures a month.  Mike says he never knew when a seizure was coming.  He would usually just wake up a couple of hours later and the people around him would tell him what happened.  Fortunately for him, he never got seriously injured during one of his seizures.  He once had a seizure while doing a presentation in American Studies and failed the class.

A couple of years into college, Mike went to see a neurologist, Dr. Nordli at Helen Hayes Hospital.  That is when he was finally diagnosed with Epilepsy. For several years, he and Dr. Nordli varied the type and dosage of the medications he took, but never got his seizures under control.  Finally  the Epilepsy Center team, including neurosurgeon, Dr. Robert Goodman , recommended that Mike consider epilepsy surgery here at Columbia Presbyterian Hospital.

Dr. Goodman worked closely with Dr. Nordli to map Mike’s seizures.  They were finally able to find the exact location in his brain called the seizure focus.  (This is the part of the brain where the seizures were originating).

In Mike’s case, this was found to be an area in the back part of his temporal lobe.  Fortunately this is an area of the brain that surgeons have had great success in treating.

During a more than six hour surgery, Dr. Goodman performed a temporal lobectomy.  The procedure began with careful mapping of the brain using computers, imaging technology and sophisticated software.  When the exact surgical location was targeted, Dr. Goodman removed a section of the skull over the area. (In Mike’s case, on the side, near the back of his head).  Then carefully, the section of his brain that was known to be the cause of the seizures was removed.

During the surgery, Dr. Goodman had to make an important decision.  He knew that the section he had to remove would affect Mike’s vision but it was a worthwhile sacrifice to enable Mike to be seizure free and live a normal life.

After the surgery, Mike’s seizures stopped completely.  As, Dr. Goodman had predicted, he did have some problems with his vision.  He couldn’t see things that were to his right, but Dr. Goodman knew that Mike could eventually compensate for that.

After being seizure free for a year, Mike was able to get his drivers license and his new life and independence kicked into high gear.  He got a part time job and because he could now drive, he enrolled in a paralegal program.  ”I always liked the law.  I saw it as a way I could help people,” Mike says. He learned to compensate very well for the vision loss, by turning his head or looking to the right

In 2000, exactly seven years after surgery, Mike told Dr. Goodman, “I am celebrating by going to work.”  Today, Mike has been working as a paralegal for AT&T for ten years.  He drives 35 miles to work every day and he just got back from a trip to Maine where he had to drive for eight hours straight both ways.

When asked what he would say to anyone with Epilepsy who is considering the surgery, his answer is simple,  ”Go see Dr. Goodman.”

Epilepsy is a general term for a group of disorders that involve regular seizures or electrical disturbances in the brain.  Epilepsy is highly variable from person to person, depending on the seizure type and location of their seizure onsets in the brain.

Many patients have seizures that are technically called complex partial seizures. These often seem to be “mild”, typically with patients stopping what they are doing and staring (often with minor physical movements). They typically last less than a minute and may occur no more than a few times a month.  However, having this type of seizure significantly affects a person’s ability to function independently and severely impairs quality of life.  In some cases they can even prove fatal.

A thorough neurological examination and highly sophisticated imaging technology is used to find the exact type and source of the seizure.  Once diagnosed, medication is typically the first line of treatment.

According to Goodman however, “Over 40% of patients with complex partial or temporal lobe type seizures do not have their seizures completely controlled by medication.  Many of these patients can be cured surgically.”

“Many of these patients,” he explains, “have seizures that have their focus (place where they originate) in a benign area of the temporal lobe.  Often, the diseased section isn’t critical to function and can be removed without significant impairment to the person.”

Surgical treatment for temporal lobe epilepsy has an exceptionally high cure rate, too.  One research study showed that 60% of patients at their one year check-up were completely free of seizures, compared with 8% of patients treated with medication only.  Some research also indicates that the cure rate may be even higher when the patients are more rigorously selected.

Dr. Goodman wants these kinds of epilepsy patients to know that this could be a possibility for them.  ”Surgery can change their lives,” he says, “make their lives normal, in fact, and unless their neurologist works with a major surgery center, they may not  know this is available either.”

Dr. Goodman says that to find out if surgery is an option, patients need to see a neurologist who, not only specializes in Epilepsy, but also has experience working with neurosurgeons who regularly perform this kind of surgery, typically at a large medical center where the diagnostic and surgical technology is available.

To learn more, see the Epilepsy Center‘s page on  Temporal Lobe Epilepsy.

Symptoms

The partial (focal) seizures may occur in patients of any age, with or without aura (a neurological warning, such as a sense of fear, an unpleasant smell, or change in perception), and can have a variety of symptoms, including rhythmic muscle contractions, abnormal movements, and abnormal sensations. Sometimes these local seizures can progress to generalized seizures that affect the whole brain.

Mesial temporal sclerosis usually results in partial (focal) epilepsy. This seizure disorder can cause a variety of symptoms such as strange sensations, changes in behavior or emotions, muscle spasms, or convulsions. The seizures usually are localized in the brain, but they may spread to become generalized seizures, which involve the entire brain and may cause a sudden loss of awareness or consciousness.

Diagnosis

Diagnostic techniques, such as electroencephalograms (EEGs), video-EEG telemetry (vEEG), computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon-emission computerized tomography (SPECT) are used to assess and visualize abnormalities and structural problems associated with epilepsy that may be targets for surgery. Functional testing, including neuropsychological testing, functional magnetic resonance imaging (fMRI), and WADA testing, may be used prior to surgery to define vital regions of the brain and limit risks associated with removal of the epileptic zone.

Treatment

Although some patients can control their seizures with anti-epileptic medication, temporal lobe epilepsy is a condition that often is amenable to surgery. Because the seizures are localized and have an identifiable source in the brain, the removal of all or part of the temporal lobe, called a temporal lobectomy, often can stop the seizures entirely.

Temporal lobectomy is the most common epilepsy surgery and is associated with high success rates and low complication rates. One recent study registered a success rate (defined by how many patients were seizure-free at one year) close to 60 percent, compared with 8 percent among patients given medication alone. Clinical experience and careful patient selection may push this number even higher. Other studies have reported higher success rates for carefully selected temporal lobe seizure patients.

Some physicians still consider temporal lobectomy an extreme procedure, citing the risks of side effects, including loss of memory, visual disturbances, and emotional change, associated with the removal of brain tissue. However, such side effects are minimized by careful patient selection and a battery of neurological tests that indicate where resection can be made to minimize effects on neurological function. Also, experts state that the portion of the brain being removed already is behaving abnormally, and therefore its removal does not usually have a profound detrimental effect on brain function.

Brain damage from traumatic injury, infection, a brain tumor, a lack of oxygen to the brain, or uncontrolled seizures is thought to cause the scar tissue to form, particularly in the hippocampus, a region of the temporal lobe. The region begins to atrophy; neurons die and scar tissue forms. This damage is thought to be a significant cause of temporal lobe epilepsy. In fact, 70 percent of temporal lobe epilepsy patients have some degree of mesial temporal sclerosis. It also appears that the mesial temporal sclerosis can be worsened by additional seizures.

Symptoms

Mesial temporal sclerosis usually results in partial (focal) epilepsy. This seizure disorder can cause a variety of symptoms such as strange sensations, changes in behavior or emotions, muscle spasms, or convulsions. The seizures usually are localized in the brain, but they may spread to become generalized seizures, which involve the entire brain and may cause a sudden loss of awareness or consciousness.

Diagnosis

The changes associated with mesial temporal sclerosis are usually identifiable on a magnetic resonance imaging (MRI) scan.

Treatment

The assessment of the extent of mesial temporal sclerosis is important because it can be a good indicator of the outcome for patients undergoing temporal lobectomy to climate seizures. For this procedure, the part of the brain containing the point at which the seizures start is removed. The best outcomes for the surgery are in patients with mesial temporal sclerosis on only one side of the brain. Also, the best outcomes are achieved with complete removal of the sclerotic medial temporal structures. This is the single most common surgery for patients with medically refractory epilepsy, has a high rate of eliminating seizures and is associated with a low incidence of significant new neurological impairments.