Pediatric epilepsy surgery is performed to treat epilepsy (seizure disorder) in children whose condition cannot be managed by medication.
Most children with epilepsy have their seizures controlled well with medication and develop normally with few limitations. However, some children experience intractable epilepsy despite aggressive treatment with antiepileptic therapy. In these children, surgical removal of the “epileptic zone” of brain tissue may be considered. In situations where this is not possible, other types of surgery may help reduce the frequency or extent of the seizures.
Although in the past, surgical treatment for epilepsy was considered only after a long period of seizures and multiple medication trials, individuals who will develop intractable epilepsy can now be identified earlier. A surgical evaluation will often be considered when a child has not responded to two or three antiepileptic medications. There is accumulating evidence that surgically curing epilepsy at an earlier age may provide a better quality of life.
There are many kinds of epilepsy. They vary by cause, symptoms, severity, brain areas affected and more. When it comes to surgical treatment, the most useful way to classify seizures is by whether they are focal (also called partial) or generalized. Focal seizures involve only one area of the brain. Generalized seizures involve the entire brain. A seizure that starts as a focal seizure may sometimes progress to become a generalized seizure. Some surgeries aim to cure focal seizures, and some aim to reduce the number or severity of generalized seizures.
Just as there are many types of epilepsy, there are many types of epilepsy surgery. Surgeries can generally be placed into one of three broad categories: resection, disconnection or stimulation.
Resection is a medical term that means “removal.” A resection may be performed if a specific brain area responsible for seizures can be identified and safely removed. Generally, the goal of this type of surgery is to completely eliminate seizures. One common type of resection is a temporal lobectomy to treat temporal lobe epilepsy. In this procedure, a small part of the temporal lobe is removed.
The Columbia Comprehensive Epilepsy Center (CCEC) and a handful of other centers are also pioneering the use of Gamma Knife radiosurgery for seizure zones in the temporal lobes. Radiosurgery uses precise beams of radiation; unlike traditional surgery, it does not require a surgical incision. However, radiosurgery is generally not performed in very young children.
The second broad category of epilepsy surgery is disconnection. This type of surgery leaves brain tissue in place but cuts certain nerve connections. Generally, the goal of this type of surgery is to reduce the severity of seizures but not to cure them. It is sometimes an option when seizures do not begin in one specific brain area that can be identified and safely removed. This may be because seizures have no defined initiation points, or have many initiation points, or have a defined initiation point that cannot be safely removed.
A common surgery in this category is the corpus callosotomy. In this procedure, a surgeon cuts the corpus callosum, the bundle of nerves that connect the left and right hemispheres of the brain. Seizures may continue to affect one half of the brain, but they cannot spread to the other half.
Another common surgery in this category is the multiple subpial transection. In this surgery, doctors take advantage of the fact that seizures tend to spread along horizontal nerve pathways, while much important nerve communication takes place along vertical nerve pathways. Surgeons sever horizontal connections between nerves to make it harder for seizures to spread.
The third broad category is stimulation. The vagus nerve stimulator is a well-known device that can be surgically implanted near the collarbone; it delivers mild electrical current to the vagus nerve and can help reduce seizures. Responsive brain stimulation (RNS) and Deep Brain Stimulation (DBS) are newer stimulation treatments being tested in adults for now.
In some cases of medically refractory epilepsy, surgery can help establish seizure control.
It is important to understand that surgery is simply another type of treatment—one that may help when non-surgical treatments have failed. Surgery is likely to benefit properly selected patients, but there can be no guarantee that it will. Also, any type of surgery carries some risk. An epilepsy team like the experienced professionals at CCEC can help individuals and their families weigh the risks, benefits and quality-of-life considerations of medical and surgical treatments. And a neurosurgeon can explain whether the goal of an individual’s surgery will be to manage (reduce the number or severity of) or cure (completely eliminate) seizures.
Before surgical planning can begin in earnest, it is critical to understand exactly where the seizures arise. Sometimes an EEG can provide this information. In an EEG, small metal discs called electrodes are placed on the scalp—the skin on the head. The electrodes record electrical activity in the brain.
But in some situations, scalp EEGs can’t give enough information about the seizures. In such cases, to get the information required for surgical planning, electrodes can be placed on the surface of or within the brain itself. A neurosurgeon performs an operation either to place subdural electrodes on the surface of the brain, or thin Stereo EEG electrodes deeper in the brain. Information about electrical activity in the brain is gathered by the electrodes, and the area causing the seizures is identified. The electrodes can also be stimulated with a tiny electrical charge. This can give doctors crucial information about the function of the precise area being stimulated by the electrodes, to determine whether or not the area can be safely removed.
After the required information has been gathered, the electrodes are removed.
When it comes to epilepsy surgery, studies consistently show that experienced neurosurgeons at neuroscience centers of excellence achieve the best possible patient outcomes. Our neurosurgeons comprise one of the most skilled and experienced epilepsy surgery teams in the world. They are leaders in the use of state-of-the-art technology and techniques, including preoperative and intraoperative brain mapping. They draw on their deep experience to choose the safest, least invasive techniques likely to provide each patient with maximum benefit.
Dr. Neil Feldstein is an expert in pediatric epilepsy surgery.
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