What is epilepsy surgery?

Surgery is a good option for children who have medically refractory epilepsy, with seizure freedom rates in some conditions of 80-90%. Riley at IU Health offers a modern approach to epilepsy surgery, including resective, disconnective, neuromodulatory and ablative procedures.

Resective surgery

This is the most common type of epilepsy surgery. Resective surgery means removing brain tissue causing seizures either from a lesion (lesionectomy), a lobe of the brain (temporal lobectomy), or a section of the brain (quadrantectomy). This form of surgery can result in no seizures in 70-80% of cases when tests identify a specific area in the brain that’s causing your child’s seizures. This means that there is a specific, localized group of abnormal brain cells that send abnormal signals and cause irregular brain activity at random. The exact spot or focus of seizure activity in the brain can be seen on an electroencephalogram (EEG) or a magnetic resonance imaging (MRI) scan. If the seizure focus can be safely removed, surgery may be the best treatment to stop your child’s seizures.

Disconnective procedures

Children with generalized seizure disorders or focal onset seizures with rapid generalization may benefit from a palliative surgery called a corpus callosotomy. This surgery involves disconnecting the two hemispheres of the brain so they cannot allow seizure activity to cause falls and injuries. This procedure can also be done through minimally invasive surgery using lasers through very small incisions. In patients with atonic seizures the procedure decreases seizure frequency by 90%.

Other patients who have seizures coming from an entire hemisphere of the brain because of a previous stroke, malformation of cortical development or genetic or inflammatory condition might benefit from a Hemispherectomy or functional hemispherotomy. While these procedures may seem overwhelming to think about, they frequently stop seizures from occurring and have surprisingly few neurological deficits.

Neuromodulation

Your child may benefit from the placement of stimulation devices in the nervous system. There are many indications for neuromodulation, which includes vagus nerve stimulation (VNS), deep brain stimulation (DBS) and responsive neurostimulation (RNS).

Vagus nerve simulation (VNS)

This therapy is reserved for patients with frequent seizures resistant to medications that come from numerous seizure-causing areas on both sides of the brain. A vagus nerve simulation (VNS) uses a generator that is surgically implanted under the skin in the left chest and an electrode array (wire) that is wrapped around the left vagus nerve and connected to the generator. The stimulator controls seizure activity by sending electrical impulses to the brain from the vagus nerve in the neck. This therapy is the most common neuromodulatory procedure and frequently decreases seizure burden by 50% but does not commonly lead to cure.

Deep brain stimulation (DBS)

This is a recently FDA approved treatment for the indication of epilepsy. Many centers are currently applying the deep brain stimulation (DBS) leads to nuclei in the thalamus to attempt to treat generalized epilepsy syndromes. Although new to the U.S., the technique has been performed in Europe and around the world since 2010.

Responsive neurostimulation (RNS)

An integrated device with a battery that is implanted in the skull and attached to two wires which are placed on or in the brain. The so-called “brain pacemaker”, this device is the only one of its kind which can sense seizures and then stimulate them to stop the seizure.

Ablation

Epilepsy patients who have very small brain areas that cause seizures may benefit from minimally invasive focal destruction by laser technology. This is called laser interstitial thermal therapy (LITT) and is performed at Riley Hospital for Children at IU Health. This data is contributed prospectively to an international registry along with other large academic centers.

Other surgical options

Some children don’t have enough evidence during our Phase I diagnosis for doctors to definitively perform one of the above procedures. In these patients, a Phase II surgery is often the next step in your child’s care plan. Phase II surgery involves the placement of electrodes on or in the brain. This is called subdural grids or strips, or stereoelectroencephalography (sEEG).

Subdural grids or strips are flat electrodes which are placed on the surface of the brain. It involves a sweeping scalp incision with bone removal from the skull (craniotomy) and then bone replacement. Your child is monitored with electrodes on the surface of the brain while in the Pediatric Intensive Care Unit (PICU) until a surgical plan is determined. Once this is determined, your child returns to the operating room for removal of the subdural grids and resection of the tissue causing seizures.

sEEG is a procedure where depth electrodes are implanted often on both sides of the brain (bilaterally) through small incisions. Your child is then woken up and these electrodes are monitored until a surgical plan can be determined, at which time he or she goes back to the operating room for removal of electrodes and either resection or ablation.

Robotic surgery

The robotic stereotactic assistant (ROSA) is a neurosurgical robot which assists the stereotactic placement of electrodes into a target with high accuracy. Riley at IU Health is the only facility in the state of Indiana that owns and operates the ROSA for highly accurate neurosurgical procedures.

Why choose epilepsy surgery?

If left untreated, frequent seizures can be physically and mentally debilitating and even fatal.

In most cases, children who have seizure surgery are free of seizures or have significantly fewer seizures and may no longer need medicines a year or two after the procedure.

Before your child is approved for seizure surgery at Riley at IU Health, he or she will complete a full medical workup with the pediatric neurology and neurosurgery teams. Children who are candidates for epilepsy surgery typically experience seizures daily or more than once a day, despite being on two or more medicines.

After all pre-surgical testing is performed, a multidisciplinary group of neurologists, neurosurgeons and neuropsychologists will meet to discuss whether your child is a good surgical candidate. The team then presents the surgical options to your family and explains the chosen procedure.

What can we expect with epilepsy surgery?

Pre-surgery evaluation

You can expect the following during the medical workup with our Epilepsy Program to determine if your child is a good candidate for seizure surgery:

A video EEG to more closely study where the abnormal activity takes place within the brain.
Structural imaging with a MRI and CT scan
A functional MRI may be performed on your child if he or she is old enough to undergo a brain MRI without sedation. This study will help to determine the location of brain function such as motor, memory and language functions in the brain. This will allow neurosurgeons to map out the functional areas of the brain to see if your child’s seizure focus overlaps with a functional area. Brain mapping also helps neurosurgeons avoid damaging functional areas of the brain during surgery.
PET or SPECT imaging to understand the metabolism of abnormal brain tissue. Neuropsychological testing will be performed to help doctors understand if any deficits exist because of the seizure focus.
An ophthalmological (eye) evaluation will help to determine if the seizure focus is affecting vision and can help prevent vision loss from occurring during surgery.
If the multidisciplinary neurosurgical team determines that your child is a good surgical candidate, a neurosurgeon will discuss surgery options with you.
Your child’s neurologist who specializes in epilepsy (epileptologist) and neurosurgeon will explain the procedure and answer your questions.

Day of surgery

You can expect the following on the day of seizure surgery:

A nurse will call you two nights before your child’s scheduled surgery to tell you when your child must stop eating and drinking (usually after midnight the night before surgery).
When you arrive at the hospital, you and your child will go to the admitting department.
Once your child is registered and admitted, you will be brought to the surgery floor.
A nurse will take you and your child to an exam room, where your child will change into a hospital gown.
The neurosurgeon will visit with you and your child to explain the procedure and answer any questions you may have.
Your child will then receive anesthesia to put him or her to sleep for surgery.
The neurosurgeon then performs the neurosurgical procedure, sometimes with the epileptologist in the operating room as well.
Often, MRI and a neurosurgical navigation system will guide the surgical team to remove the area of the brain where seizures originate.
Electrodes are sometimes placed on the surface of the brain during surgery to monitor for seizure activity.
After the seizure focus is removed, the neurosurgeon will close the surgery opening, replace the skull and close the scalp over the skull.
Your child will then be moved to a recovery area for close monitoring until he or she wakes up.

Riley at IU Health has created a surgery preparation video to help you and your child know what to expect the day of their surgery. Visit our preparing for surgery page to learn more.

After your child’s surgery

You can expect the following after seizure surgery:

The neurosurgeon will prescribe pain medicine to keep your child comfortable.
The doctor will also prescribe seizure medicines to be taken for a year or two after surgery.
Your child will stay in the hospital for two or three days after the seizure surgery.
Your child will be monitored for seizures and signs of infection.
Rarely, a child will have a seizure after surgery. If this happens, an EEG will be performed and medicines may be adjusted.
Your child will continue regular checkups with the neurosurgeon and a neurologist.

Your child should return to normal activities soon after recovering from the procedure.

Key Points to Remember

Epilepsy surgery is performed to stop debilitating, frequent seizures that do not respond to medicines.
Children with a clearly identifiable focal point in the brain where seizures originate are good candidates for seizure surgery.
There are many different types of epilepsy surgery but resection surgery is the most common.
After epilepsy surgery, most children have many fewer or no longer experience seizures and may be able to come off their seizure medicines.
The Epilepsy Program at Riley at IU Health is capable of performing the most complex epilepsy surgeries including hemispherectomy as well as minimally invasive robotic and laser ablation surgeries.

Locations

In addition to our primary hospital location at the Academic Health Center in Indianapolis, IN, we have convenient locations to better serve our communities throughout the state.