Surgery for Epilepsy Sooner Rather Than Later

Epilepsy surgery should not be a “last-resort.” Epilepsy surgery is a proven method to improve and potentially completely control seizures in selected patients. Epilepsy surgery is considered in patients who have not had control of their seizures despite trials with 2 or more antiepileptic drugs (AEDs). Epilepsy surgery can dramatically change a patient’s life. The chance of complete seizure control can be > 70% for some patients.

Despite a proven track record, it is typically many years from the time the patient starts having seizures to the time they finally have epilepsy surgery. Studies suggest that patients are finally referred for epilepsy surgery after 20 years of seizure activity. There is mounting data that performing epilepsy surgery sooner rather later may be helpful. Surely, it does not take 20 years to see if 2 or 3 seizure medications are going to control the seizures! Please note- if a patient has not had his or her seizures controlled after trying 2 AEDs, the chances of having AEDs completely control the seizures is quite low. That is why epilepsy surgery is considered in those who have tried 2 AEDs.

Of course, epilepsy surgery has risks. Remember, the surgery involves having the surgeon remove a piece of the skull and removing a piece of brain tissue. This brain tissue is the area of the brain that the seizures were starting. By removing this abnormal tissue, the seizures can be controlled. Risks include stroke, infection or memory problems. With careful evaluation, these risks can be minimized.

A recent article has been published entitled “Early Surgical Therapy for Drug-Resistant Temporal Lobe Epilepsy.” (Engel, JAMA, 2012). The goal of the study was to compare: 1) epilepsy surgery to 2) continued AED therapy without epilepsy surgery. The study looked at the effect of surgery on seizure control and the effect on quality of life. The patients in the study had tried 2 AEDs and were still having seizures. The seizures had to be disabling for no more than 2 consecutive years. This is important—this is the “early” part of the study. Rather than waiting for many many years, the study sought to evaluate those who had seizures for only a short period of time (< 2 years). A total of 38 patients (18 men and 20 women) with temporal lobe epilepsy were included in the study. 15 patients were randomized to the surgery group and 23 patients were randomized to the medical group (medical group – treated with AED only, did not have surgery). It should be noted, the surgery patients did continue their AEDs.

Results:

Surgery group: 11 of 15 patients were seizure free.
Medical group: 0 of 23 patients were seizure free. (P < 0.001)
Quality of life scores were better in the surgery group, but the findings did not reach statistical significance (p=0.08).
Surgery group adverse events: 1 patient had a postoperative stroke. Neurologic symptoms resolved.
Medical group adverse events: 3 patients went into status epilepticus (prolonged and potentially dangerous seizure activity).

The authors concluded that early surgery is superior to AED treatment alone for controlling seizures in patients with temporal lobe epilepsy. This study clearly supports the idea that you should not wait years and years for surgery. If a patient is not responding to AEDs, then surgery should be considered sooner rather than later.

The study suggested that quality of life was also better in the surgery group, but the small number of patients resulted in a non-significant finding. It should be noted that the study was stopped early because it was a challenge to recruit patients that met the inclusion criteria. The actual study had a total of 38 patients—the goal was 200. Because of the small numbers, the results need to be interpreted with appropriate caution.

This study supports the recommendation of the American Academy of Neurology: if a patient’s seizures are not controlled by 2 AEDs, then evaluation for possible epilepsy surgery should be considered. This should happen sooner rather than later!

References

Engel J, McDermott M, Wiebe S, et al. Early surgical therapy for drug-resistant temporal lobe epilepsy. JAMA 2012;307:922-930.

James White, MD

Dr. White has been practicing as a full-time epileptologist since 1999. His practice focuses on optimizing the diagnosis and treatment of patients with seizure disorders. Dr. White’s special interests include patient education, improving the side-effect profile of seizure medications, and epilepsy surgery.

7 Responses to “Surgery for Epilepsy Sooner Rather Than Later”

Kari April 27, 2012 at 4:28 pm

I would have to agree. If medications are not helping after even a year or even two then I would take the next step. I ended up having to wait 21 years to be sent to the right doctor and then another 2 years for the tests to take place. So after 23 years of dealing with the seizures I finally was able to go through with the surgery. Since then I have been seizure free for 9 years now. I am still on one medication but that’s down from three I was on. So it was definitely worth it. If I had a choice though I would not have waited that long for sure. I would be able to have more in life accomplished today if I was able to get it done sooner.

Reply By: James White, MD April 30, 2012 at 7:50 am

Thank you Kari. Although epilepsy surgery is a major surgery, the benefits can clearly be worth it for some patients. Thank you for sharing your story.An important message that we want to deliver (and your history illustrates this perfectly), is that patients should not wait for years (or event decades!) to haver surgery, if surgery is the right treatment.
Thank you.
James White, MD

Steven Harris, MD April 30, 2012 at 2:12 pm

I am a physician with partial onset seizures. I underwent brain surgery in 1986 at Rush Pres. St. Lukes in Chicago …….Dr. Frank Morrell, and Dr. Michael C. Smith. The surgery essentially saved my life and my career.
The sooner the surgery, the better the outcome!! Unfortunately the surgery was experimental at the time, but it still allowed me to practice medcine for 17 years. I would love to help others with epilpsy. LISTEN TO YOUR DOCTOR!!!!!!!!!!1
I can be contacted via my email (sharrismd@aol.com).
Best Regards, Steven Harris, MD

James White, MD April 30, 2012 at 2:25 pm

Thank you Dr. Harris. We greatly appreciate your comments!
James White, MD

Dave Doer May 5, 2012 at 8:23 pm

I am a carpenter with too many head injuries. I was diagnosed with epilepsy a decade ago. Six months ago I was surfing the net, doing my epilepsy research, and discovered the website, Citizens United for Research in Epilepsy, or CURE. These people gave links for research studies, and are encouraging every epileptic, and their care-givers everywhere to volunteer for these studies. I volunteered at the National Institute of Neurological Disorders and Stroke (NINDS) which is one of the institutions at The National Institutes of Health. Two months after my initial inquiry, I was at the NINDS to begin their studies. I had all the tests including several EEG’s, a Video EEG, MEG, several MRI’s, sub-dural implants, other tests, and then a lobectomy. My lobectomy was performed six weeks ago. I am home now. This has been one of the most exciting experiences of my life. I am glad that I volunteered! The scientists, doctors, neurologists, neurosurgeons, nurses, and technicians at the NIH are amazing people. They thanked me for volunteering, They told me that I am a good man for allowing them to study my brain. I have been cured because of that lobectomy. NO MORE SEIZURES!! I am so thankful that I am without those crazy seizures. Thank you, NIH! I encourage every epileptic to volunteer and do their part to find a cure. there is hope because there is a cure! Peace.

Reply By: James White, MD May 7, 2012 at 8:50 am

Thank you Dave! Great and important comments!
James White, MD

Deb Thoennes June 22, 2012 at 7:28 am

I’ve seen this video circulating in the epilepsy forums and websites regarding a type of laser surgery being used for gelastic seizures: http://abcnews.go.com/Health/laughing-matter-surgery-helps-kids-dangerous-giggling-seizures/story?id=16353497#.T9p947X4J4V It seemed to me to be an incredible breakthrough to help kids with seizures of this type. Since viewing the video, I’ve been wondering if this laser technology could be applied to actual brain tissue where seizure activity is coming from (rather than just a lesion causing the seizure being removed, as was the case in the video), making it easier to get to areas not easily accessible with traditional epilepsy surgery techniques involving removing that section of the brain. Then I read this excerpt from the Epilepsy Therapy Project website under the heading, “Promising New Epilepsy Therapies Featured at 2012 Epilepsy Pipeline Update Conference”:

“Visualase, Inc. has developed a laser ablation system that enables minimally invasive neurosurgical procedures. The technology produces precise thermal destruction of undesirable tissue in the brain, including epileptic foci deep in the temporal lobe, through a tiny keyhole. Patients most often leave the hospital within 24 hours of the procedure, and the safety profile has been excellent. The technology has been successfully used in more than 120 neurosurgery procedures. The Visualase system is now being evaluated at several leading centers throughout the U.S. The hope is that a minimally invasive approach to neurosurgery will make more patients interested in pursuing surgical options”.

Maybe it’s not used for deeper areas of the brain?