What to do next if Medications Fail To Work?
　　　
　　　In some cases, standard medications fail to provide control, and patients are referred to Comprehensive Epilepsy Centers such as ours for expert management of drug therapy, experimental anti-epileptic drugs, and consideration for epilepsy surgery.
　　　

Why Consider Surgery For Epilepsy? 　
　　　
　　　Children and adults with hard-to-manage seizures may be considered for epilepsy surgery when treatment with three or more anti-epileptic medications fails. The consequences of uncontrolled, frequent seizures may be:
　　　　　
　　　* Physical (such as falling into subway tracks, burns, or other self-injury during a seizure) damage.
　　　* Disruption of learning, attention and memory.
　　　* Social (stigma, isolation, employment limitations) problem.
　　　　
　　　Patients may also be considerably impaired by side effects of anti-epileptic medications.
　　　　
　　　Any or all of these reasons may lead a patient - or even parents of a small child- to think about neurosurgery to improve seizure control.
　　　　　

What Are The Steps Leading To Epilepsy Surgery?
　　　　
　　　Extensive evaluation is required to bring a child or adult to epilepsy surgery. We must determine the "source" of the seizures; then, we must predict any major problems with speaking, understanding or other abilities if we remove the "source", or part of the brain responsible for the seizures. We carefully tailor our neurosurgical approach to (1) obtain maximum seizure control and (2) minimize any dysfunction or difficulties afterward. Our aim, always, is to improve quality of life.
　　　
　　　Team members - neurologists, neurosurgeons, neuroradiologists, neuropsychologists, nurse specialists, language therapists, occupational and physical therapists- work together to find evidence that points to a consistent part of the brain as the source of seizures in that particular child or adult.
　　　　
　　　The diagnostic testing done to identify the "source" of seizures includes:
　　　
　　　* EEG, or electroencephalogram, records brain waves and often guides us in identifying areas of the brain which have abnormal electrical discharge. The EEG, even in between seizures, is often helpful in detecting the part of the brain most involved in seizures.
　　　　
　　　* Brain CT scan and MRI help us identify structural problems in the brain which may be responsible for seizures, such as lesions, benign tumors or small areas of inflammation or malformation.
　　　　
　　　* Language, memory, concentration, motor, visual-spatial and other skills are assessed during neuropsychology testing, looking for areas of strength and weakness. Often parts of the brain severely affected by epilepsy do not work quite as well as other parts of the brain. Testing for subtle differences may further help us identify these "trouble spots".
　　　　
　　　* PET scan (a study of brain energy levels) and SPECT (a study of regional blood flow in the brain) help us identify areas of brain abnormality, which may be linked with seizures.
　　　　
　　　* Long-term Video-EEG Monitoring often helps us to localize, or determine the part of the brain "responsible" for seizures. During the long-term video-EEG monitoring, we simultaneously record the patient's EEG (brain wave pattern) with a video recording of his behavior.
　　　　　
　　　We may hospitalize the person for about a week and continue the video-EEG recording day and night, because we need to record the person's actual seizures, which may happen at any time.
　　　
　　　As we analyze the video-EEGs, sometimes in slow motion, we can often trace how electric "misfiring" in the brain brings about the patient's changes in behavior and movement during his seizure. Most persons with uncontrolled epilepsy have patterns of seizures, which occur again and again in the same way. Analyzing the patterns of altered behavior and movement often helps us decide the likely source in the brain for that person's seizures.
　　　
　　　We sometimes reduce a person's anti-epileptic medications while they are hospitalized for video-EEG monitoring, in order to increase the chances of recording his seizures during the hospitalization. On reduced amounts of medication, the person may have more seizures than he usually does in a short period of time, in a safe, supervised hospital setting where nurses and doctors are expertly prepared to manage seizures.
　　　　　　
　　　Localizing the seizures, or finding out where they start in the brain, is essential when we think about surgery to control seizures. That is why recording several seizures - both the patient's brain waves and behavior on video-EEG - is so important in the process of evaluation for epilepsy surgery.

　　　　　　　　
Why Perform So Many Tests?
　　　　
　　　It really does sound like a great many tests to perform on one adult or child. However, neurosurgery to remove the abnormal part of the brain that is causing seizures is a very serious decision for a person and his family. It is essential to collect evidence to be certain that removing one small area of the brain would most likely improve the seizures, and therefore the overall quality of life.
None of the diagnostic tests discussed thus far are invasive, and little risk is involved. The information gathered is fully shared with the patient and their family, so that they may make an informed decision about whether to proceed with epilepsy surgery.
　　　

What If We Are Still Not Certain of the Source of Seizures?
　　　
　　　Sometimes, we have fairly strong evidence that a patient's seizures are coming again and again from the same part of the brain, but the EEG (electroencephalogram) does not tell us exactly the localization. This may happen if the seizures start very deep in the brain (for example, very deep in the frontal lobe). Seizure disturbances may not "show up" in the recording we do.
　　　　　
　　　Another possibility is that the seizure really does start in one small part of the brain, but it spreads so quickly in the brain, like a spark that quickly becomes a fire. When the spread of the seizure happens so quickly, sometimes the EEG recording we do only captures that seizure when all of the brain is involved, when it has generalized-and we cannot identify the area responsible for the initial "spark".
When the EEG doesn't show us the source of the seizures clearly, but we are convinced - by watching the patient's seizure pattern, or by the findings in the MRI, PET, neuropsychology or other testing-that the patient's seizures most likely are partial seizures which could be helped by epilepsy surgery, we consider going a few steps further.
　　　
　　　We can overcome the problem of not being close enough to the source by placing the EEG electrodes closer to the brain. Through a small operation, EEG electrodes called intracranial monitoring devices can be placed on the surface lining the brain (epidural or subdural) or even deeper in the brain. We then do long-term video-EEG recording, and record multiple seizures. By having seizure recording devices so much closer to the source, we can resolve the questions of where the seizures begin. While the placement of these intracranial monitoring devices is an invasive procedure, requiring a small operation, the procedure is safe, and gives us a great deal of information with a minimum of risk. More information about intracranial monitoring, if needed in your patient's case, is available through the Comprehensive Epilepsy Center.
　　　　　　

What Types of Seizures Can Be Helped by Epilepsy Surgery?
　　　　
　　　One type of seizure that can be helped by epilepsy surgery is the partial seizure, which begins in a small part of the brain. A person with partial seizures may have abnormal jerking or sensation in part of his body, may experience sudden fear or even unusual visions, smells or sounds.
　　　　
　　　In addition, many seizures which may appear to be generalized, or involve all of the brain at once, prove - through careful investigation - to actually begin in one small part of the brain, and can be improved or controlled through epilepsy surgery. Most tonic-clonic seizures, also known as convulsions or grand mal attacks, begin as partial seizures, then rapidly spread, or generalize, to the rest of the brain. When seizures are not controlled by conventional medical treatment, we begin careful investigation to see if generalized seizures actually begin in one small part of the brain, which might then be treated surgically. Still other types of seizures can be reduced in severity by interrupting certain nerve fiber pathways in the brain, thus preventing their spread.
　　　　　

Will Brain Surgery Create Additional Problems?
　　　　
　　　This is a critical question for all individuals involved in epilepsy surgery. Some of the brain tissue that is responsible for seizures is abnormal tissue, such as scar tissue, tumor, or tissue that improperly migrated or "landed" in the brain during early fetus development. The removal of abnormal tissue that truly never belonged in the brain may control the seizures and will not cause any change in the person's functioning.
　　　　　
　　　In some cases, the brain tissue which is abnormally excited and gives rise to seizures is located near brain tissue which is important for speaking, understanding, moving, remembering or other important human abilities. We do much careful investigation to determine the function of an area considered for surgical removal. Testing is done where we briefly interrupt the function of the part of the brain considered for surgical removal. We then make sure that the child or adult can still speak, understand, wiggle fingers, make puppets, cut sandwiches and do all the things he can ordinarily do - even with that part of the brain not working. In some cases, we do centimeter-by-centimeter functional mapping of the brain, using intracranial electrodes. In all cases, we work very hard to be sure that any proposed surgery to control seizures will not create any long-term problems for the patient. All information gathered from functional mapping of the brain is shared with the patient and his family, so that an informed choice may be made about surgery. Our neurosurgical staff proficiently meets the needs of adults and children during all stages of surgical intervention for epilepsy.
　　　　　

What Are the Results of Epilepsy Surgery?
　　　　
　　　Some patients are seizure-free after surgery; most have a great reduction in seizure frequency and severity. Many patients who do undergo surgery to remove the small part of their brain responsible for their seizures eventually improve in language or memory several months after the surgery. The improved seizure control allows adults to begin to pursue lifestyle possibilities, and children to maximize their development.
　　　　
　　　The process of evaluation for epilepsy surgery is a long, careful one, to ensure that the neurosurgical approach, if chosen, is a safe and desirable option. For children and adults whose seizures have not been controlled by medications, neurosurgical intervention for intractable epilepsy is an exciting treatment possibility.