Rodrigo Zepeda, M.D. Answers Questions On: Surgical Evaluation for Treating Epilepsy

About 30 percent of patients with epilepsy don’t respond to medications, and those are the patients we would consider for surgical treatment options.

We’ll try everything we can with medications first – adjusting the dosage, trying different types of medicine – because that’s an easier way to treat the condition. But medication works for only 70 percent of people with epilepsy, so for other patients we have to try different measures.

After seeing a patient and determining his or her epilepsy is intractable (resistant to medication), then we would admit that patient to the Epilepsy Monitoring Unit (EMU). In the EMU, we place electrodes on the patient’s head, reduce medication levels, and monitor the patient for as long as it takes – anywhere from 24 hours to several days. The goal is to get an EEG recording of one or several seizures.

With the EEG, we can see what the patient’s seizures look like and can determine if the seizures are focal, meaning they originate in one area of the brain, or generalized, meaning they start from the whole brain at the same time.

We’ll then do a series of specialized imaging, including a high-resolution MRI and a PET scan. We’ll also get a neuropsychological evaluation because looking at the cognitive functions can also help us identify brain areas that could be impacted by seizure activity.

After all of this, we’ll present all of the information to a committee that includes everyone on the epilepsy care teams. We’ll give our opinions and reach a consensus about whether to go forward with surgery.

If we don’t feel we have what we need to recommend surgery, then we will circle back and study the patient’s seizures further.

This can include intracranial monitoring, where we actually place electrodes directly on the brain instead of on the scalp. We use a specialized robot to surgically place the electrodes in the areas we think are causing the seizures, and then we monitor the patient’s seizure activity again, with the new electrodes providing even more precise readings and imaging.

After we’ve done this study, we should have enough information to determine whether surgery would be safe and effective for this patient.

There are other options available, including a responsive neurostimulator device. In this treatment, we place an electrode in the area of the brain where the seizures originate and a device to read the brain’s activity. When the device detects the onset of a seizure, it zaps it with an electrical current to stop the seizure from happening. This can be very effective for some patients.

Devices and medications are getting better all the time, as well. Almost certainly, there will continue to be better and newer ways to treat difficult cases of epilepsy in the future.