Surgical Treatments for Epilepsy

Abstract

PURPOSE OF REVIEWMore than 20 new antiseizure medications have been approved by the US Food and Drug Administration (FDA) in the past 3 decades; however, outcomes in newly diagnosed epilepsy have not improved, and epilepsy remains drug resistant in up to 40% of patients. Evidence supports improved seizure outcomes and quality of life in those who have undergone epilepsy surgery, but epilepsy surgery remains underutilized. This article outlines indications for epilepsy surgery, describes the presurgical workup, and summarizes current available surgical approaches.RECENT FINDINGSClass I evidence has demonstrated the superiority of resective surgery compared to medical therapy for seizure control and quality of life in patients with drug-resistant epilepsy. The use of minimally invasive options, such as laser interstitial thermal therapy and stereotactic radiosurgery, are alternatives to resective surgery in well-selected patients. Neuromodulation techniques, such as responsive neurostimulation, deep brain stimulation, and vagus nerve stimulation, offer a suitable alternative, especially in those where resective surgery is contraindicated or where patients prefer nonresective surgery. Although neuromodulation approaches reduce seizure frequency, they are less likely to be associated with seizure freedom than resective surgery.SUMMARYAppropriate patients with drug-resistant epilepsy benefit from epilepsy surgery. If two well-chosen and tolerated medication trials do not achieve seizure control, referral to a comprehensive epilepsy center for a thorough presurgical workup and discussion of surgical options is appropriate. Mounting Class I evidence supports a significantly higher chance of stopping disabling seizures with surgery than with further medication trials.

Specific consistency score for rational selection of epilepsy resection surgery candidates

“…When considering the indications for epilepsy surgery, decisions are often made by several epileptologists and experts in related fields such as radiology, psychiatry, psychometry, and neurosurgery via group discussion 2 . The final judgment may vary among individuals and institution 29 . To reduce this variability, some scores have been proposed 17–20 .…”

“…2 The final judgment may vary among individuals and institution. 29 To reduce this variability, some scores have been F I G U R E 3 Associations between the Specific Consistency Score (SCS) or modified SCS and each of the three parameters by univariate analysis. SCS was significantly associated with all three parameters in all evaluated patients (A) and non-mesial temporal lobe epilepsy (MTLE) patients (B).…”

Neuroimaging of Epilepsy

“…Although most patients with epilepsy can achieve control of seizures with antiseizure medications alone, a substantial proportion of patients have drug-resistant epilepsy. Where resources are available, all such patients should be referred to a comprehensive epilepsy center for a presurgical evaluation; for more information about this, refer to the article “Surgical Treatments for Epilepsy” by George W. Culler IV, MD, and Barbara C. Jobst, MD, PhD, FAAN, 26 in this issue of Continuum . In simple terms, epilepsy surgery consists of carefully identifying the seizure focus within the brain and surgically removing it when safe to do so.…”

Criticality in probabilistic models of spreading dynamics in brain networks: Epileptic seizures

“…About 30% of the cases are diagnosed as pharmacologically resistant epilepsy. Main alternative therapeutic approaches consist of surgical resection of identified epileptogenic brain areas [3,4] or electrical stimulation [5][6][7][8]. In the particular case of focal epilepsy, seizures that initiate in a localized brain region may or may not spread across the brain.…”