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NeuroNow - Surgery Sooner Rather Than Later May Be Best for Drug-Resistant Epilepsy

Fall 2009

Surgery Sooner Rather Than Later May Be Best for Drug-Resistant Epilepsy

Date: November 30, 2009

George Jallo and Fred Lenz: When medications aren’t controlling seizures, there are alternatives.
George Jallo and Fred Lenz: When medications aren’t controlling seizures, there are alternatives.

Many epilepsy patients spend years searching for a drug that can control their seizures, a quest that can lead them to try a dozen or more different medications. Until recently, many of those patients and their doctors considered surgery a last resort: Patients receiving surgery for epilepsy have had the condition, on average, for 22 years.

Now some epilepsy specialists are shifting their view; they say that patients with certain forms of the disorder, whose seizures cannot be controlled with medication should not wait that long before considering surgery. “Seizure surgery is really not a last option,” says neurologist Greg Bergey, director of the Johns Hopkins Epilepsy Center. “There’s more of an appreciation that surgery can render people seizure free and should be considered after several years if medications do not provide seizure control.”

Not having seizures managed isn’t a reasonable option, says neurosurgeon Fred Lenz. The health consequences include memory loss, an increased risk of accidents and reduced life expectancy.

What’s brought the change in philosophy about surgery, Lenz explains, arises from a growing body of research on the 20 percent to 40 percent of epilepsy patients who fall into the “intractable” category — most with the form called temporal lobe epilepsy.

In one set of studies, results suggest that patients whose seizures persist even after they’ve tried as few as two or three different epilepsy drugs are unlikely to find effective medication. “The odds of improving your chances on the third or fourth or fifth drug are vanishingly small,” says Lenz.

Still other research examines how patients fare after surgery for temporal lobe epilepsy. In the typical procedure, surgeons remove the small, focal portion of brain tissue that generates a patient’s seizures. Some 60 percent to 90 percent of patients who undergo an operation no longer have disabling seizures, even though some may still need to take anti-epilepsy medication.

Technical advances have influenced most neurosurgeons’ views on epilepsy surgery. The ability to image seizures in the brain through MRI and PET has improved dramatically in recent years. In addition, epilepsy specialists now have improved methods to analyze the electrical activity of a patient’s seizures using advanced digital recording technology. “And the quality of the technology has improved a lot,” says Lenz. “We can now localize seizures’ focal points in the brain with a definition we never had before.”

Hopkins neurosurgeons perform about 45 epilepsy operations per year, about one quarter of them pediatric cases. The latter reflects a pediatric shift to the sooner-is-better-than-later approach for children with intractable seizures, says pediatric neurosurgeon George Jallo, who’s operated on children as young as 1 year. (In contrast to adults’ temporal lobe seizures, most children’s seizures arise in the frontal lobe or other non-temporal areas.) “Children tend to do great,” Jallo says. “They generally recover better than adults.”

That said, surgery isn’t appropriate for every epilepsy patient. It generally works best on those whose seizures originate in a relatively small focal area of the brain, says Lenz. Patients with more diffuse seizures or with seizures that come from multiple regions or both sides of the brain are often not good surgical candidates.

As in any form of brain surgery, there are risks, including stroke, hemorrhage and infection. “Patients need to assess these and the likely benefits carefully with a neurologist before considering surgery,” advises neurologist Gregory Krauss. Still, for many patients, he adds, the consequences of continued uncontrolled seizures far outweigh any risks.

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