Refractory epilepsy

Also called as medically intractable epilepsy, therapy resistant epilepsy, and difficult to control epilepsy.

Clinical criteria

• Epilepsy not controlled by 2 or more appropriate antiepileptic drugs used in their optimal dosage

• Adults who continue to have seizures even after 2 yrs of regular treatment

• Pediatric epilepsy- if they present with epileptic encephalopathy, infantile spasms, catastrophic onset of epilepsy, frequency of more than 1 month, and disabling seizures.

Why surgery in epileptic patients

• 70- 75% of epileptic patients can be managed by proper antiepileptic medications
• The remaining 20- 25% patients come under medically intractable epilepsy, which need surgical intervention.
• Having frequent or severe seizures often restricts you from driving, doing certain kinds of work, and other activities.
• If surgery is indicated it should be done as early as possible without any delay.
• Early surgery for some forms of childhood epilepsy may end seizures and prevent or reverse developmental delays.

Indications for surgical management

Medically intractable epilepsy with identifiable lesion on CT scan or MRI and EEG are the potential candidates for epileptic surgery

Medical intractable epilepsy even if imaging is negative

Those epileptic attacks which frequently alter the consciousness

Tests and diagnosis- before surgery

• MRI
• CT plain or contrast
• EGG

• VEGG

• And routine blood tests

Types of brain surgery in epilepsy

Resection or resective surgery

• In this type, the surgeon removes the area of the brain that causes the patient's seizures.
• The most common example of this type of surgery is the temporal lobectomy, in which part of the temporal lobe of the brain is removed.
• The goal of resective surgery for epilepsy is most often cure of the seizure disorder.

Epileptic surgeries interrupting the nerve pathway

• It’s less common type of epilepsy surgery that interrupts nerve pathways that allow seizures to spread. The term disconnection is sometimes used to describe it.

• Examples of this kind of procedure are corpus callosotomy and multiple subpial transections

• Disconnection procedures are generally thought of as providing relief, but not a cure.

Advantages of epileptic surgery

• Risk of surgery has been shown is less than the risk associated with natural course of epilepsy
• Surgery has a high chance of achieving seizure freedom in 60- 70% of cases. In some cases resective surgeries can be curative.

• Resective surgeries include lesionectomy, amygdalo hippocampectomy with or without temporal lobe resection, and multilobar resection.

• Non resective surgeries include multiple subplial transection, corpus callosotomy and vagus nerve stimulation

Disadvantages of epileptic surgery

• 30- 40 % of patients after epileptic surgery will have only reduction in seizure frequency but not cure.

• People with severe illnesses, psychiatric disorders, or neurological problems other than epilepsy may need evaluations from more specialists

• Epilepsy surgery involves removing part of your brain. It can affect your brain function, although the effects may be less bothersome than those caused by the epilepsy itself.

Risk following epileptic surgery

• Memory and language difficulties
• Temporary double vision
• Reduced visual field
• Partial one- sided paralysis
• Sometimes increasing number of seizure frequency