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Epilepsy Surgery E Feoli MD North East Regional Epilepsy Group 2012.

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Presentation on theme: "Epilepsy Surgery E Feoli MD North East Regional Epilepsy Group 2012."— Presentation transcript:

1 Epilepsy Surgery E Feoli MD North East Regional Epilepsy Group 2012

2 Referrals Comprehensive Epilepsy Center Evaluation: History/Exam EEG Imaging Controlled Not Controlled Video-EEG Non-epileptic Events Epilepsy Medical Management Surgical Management Refer

3 The Poorly Controlled, Intractable Seizure Patient Despite medical management, patient continues to have frequent, debilitating seizures Despite medical management, patient continues to have frequent, debilitating seizures Commonly on polytherapy (more than one medication) Commonly on polytherapy (more than one medication)

4 Candidates for Epilepsy Surgery Persistent seizures after initial attempts at treatment (at least 2 appropriate AEDs at reasonable doses) Persistent seizures after initial attempts at treatment (at least 2 appropriate AEDs at reasonable doses) Impaired quality of life due to ongoing seizures Impaired quality of life due to ongoing seizures For focal resection: single seizure focus that can be safely removed For focal resection: single seizure focus that can be safely removed Palliative procedures: corpus callosotomy, subpial transections, VNS, others Palliative procedures: corpus callosotomy, subpial transections, VNS, others

5 Epilepsy Surgery To determine where the seizures are coming from To determine where the seizures are coming from Video-EEG monitoring MRI MRS: PET: SPECT:

6 Goals of Video-EEG Monitoring Epilepsy vs. non- epileptic events Epilepsy vs. non- epileptic events Characterize epilepsy type Characterize epilepsy type Pre-surgical evaluation Pre-surgical evaluation FOCAL EPILEPSY

7 EEG Slide /ROUTINE

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9 Brain MRI

10 MRI

11 MRI

12 SPECT SCAN

13 PET SCAN

14 Epilepsy Surgery To make sure that it is safe To make sure that it is safe Wada test: to study speech and memory Neuropsychological testing: mental functions (IQ, memory, attention) and personality assessment Psychological evaluation Ophthalmologic evaluation

15 Epilepsy Surgery Some cases in which the localization is not clear or where function could be affected will require INVASIVE ELECTRODES Some cases in which the localization is not clear or where function could be affected will require INVASIVE ELECTRODES Depth electrodes Depth electrodes Subdural electrodes Subdural electrodes

16 Subdural Electrodes

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18 Types of Epilepsy Surgery Temporal Lobectomy Temporal Lobectomy Extratemporal Resections Extratemporal Resections Hemispherectomy Hemispherectomy Corpus Callosotomy Corpus Callosotomy

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20 Outcome after epilepsy surgery Anterior temporal lobectomy Anterior temporal lobectomy 70-80% seizure free 70-80% seizure free Neocortical resection Neocortical resection With lesion: 50-80% seizure free With lesion: 50-80% seizure free Without lesion: 30-50% seizure free Without lesion: 30-50% seizure free Hemispherectomy Hemispherectomy Significant improvement Significant improvement Corpus Callosotomy Corpus Callosotomy Significant improvement for drop attacks Significant improvement for drop attacks

21 Complications of surgery Low rate of complications Low rate of complications Infections Infections Bleeding Bleeding Anesthesia Anesthesia Function Function

22 Vagus Nerve Stimulator (1997) Intractable epilepsy patient without focus or desires interim step before epilepsy surgery Intractable epilepsy patient without focus or desires interim step before epilepsy surgery Goal is to reduce amount/severity of seizures vs. cure Goal is to reduce amount/severity of seizures vs. cure Device surgically implanted in left chest/axilla area Device surgically implanted in left chest/axilla area Coils around left vagus nerve Coils around left vagus nerve Stimulation is automatic; patient can additionally stimulate device if aura Stimulation is automatic; patient can additionally stimulate device if aura

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24 VNS Therapy VNS: <10% seizure free, VNS: <10% seizure free, 30-50% with at least 50% seizure decrease, more with lesser improvement; effects on seizure severity? 30-50% with at least 50% seizure decrease, more with lesser improvement; effects on seizure severity?

25 Deep Brain Stimulation (DBS)

26 Neuropace Neuropace

27 Conclusion -Not all patients with refractory epilepsy are surgical candidates. -Patients with refractory epilepsy are candidates for surgery. -Patients with FOCAL refractory epilepsy are candidates for surgery. -Multiple steps are required before your doctor concludes that you are a surgical candidate. -

28 Conclusion You might be a good surgical candidate however a RESECTIVE procedure might not be possible, due to the proximity o the seizure focus to eloquent cortex

29 Thank you Thank you


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