Download - Epilepsy Surgery
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Epilepsy SurgeryEpilepsy SurgeryE Feoli MDE Feoli MD
North East Regional Epilepsy North East Regional Epilepsy GroupGroup20122012
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ReferralsComprehensive
EpilepsyCenter
Evaluation:●History/Exam
●EEG●Imaging
Controlled Not Controlled
Video-EEG
Non-epilepticEvents
Epilepsy
MedicalManagement
SurgicalManagementRefer
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The Poorly Controlled, Intractable The Poorly Controlled, Intractable Seizure PatientSeizure Patient
Despite medical management, patient Despite medical management, patient continues to have frequent, debilitating continues to have frequent, debilitating seizuresseizures
Commonly on polytherapy (more than one Commonly on polytherapy (more than one medication)medication)
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Candidates for Candidates for Epilepsy SurgeryEpilepsy Surgery
Persistent seizures after initial attempts at Persistent seizures after initial attempts at treatment (at least 2 appropriate AEDs at treatment (at least 2 appropriate AEDs at reasonable doses)reasonable doses)
Impaired quality of life due to ongoing Impaired quality of life due to ongoing seizures seizures
For focal resection: single seizure focus For focal resection: single seizure focus that can be safely removedthat can be safely removed
Palliative procedures: corpus callosotomy, Palliative procedures: corpus callosotomy, subpial transections, VNS, otherssubpial transections, VNS, others
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Epilepsy SurgeryEpilepsy Surgery To determine where the seizures are coming To determine where the seizures are coming
fromfromVideo-EEG monitoringVideo-EEG monitoringMRIMRIMRSMRS: : PETPET: : SPECTSPECT: :
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Goals of Video-EEG MonitoringGoals of Video-EEG Monitoring Epilepsy vs. non-Epilepsy vs. non-
epileptic eventsepileptic events
Characterize epilepsy Characterize epilepsy typetype
Pre-surgical evaluationPre-surgical evaluationFOCAL EPILEPSY FOCAL EPILEPSY
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EEG Slide
99-10-31/ROUTINE
Fp1-F7
F7-FT9
FT9-T7
T7-P7
P7-O1
Fp2-F8
F8-FT0
FT0-T8
T8-P8
P8-O2
FT9-FT0
A1-A2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
ECG-RFECG-RF
SaO2(%)
HR(bpm)
Comment
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
spike
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Fp1-F7
F7-FT9
FT9-T7
T7-P7
P7-O1
Fp2-F8
F8-FT0
FT0-T8
T8-P8
P8-O2
FT9-FT0
A1-A2
Fp1-F3
F3-C3
C3-P3
P3-O1
Fp2-F4
F4-C4
C4-P4
P4-O2
ECG-RF
SaO2(%)
HR(bpm)
Comment
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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Brain MRIBrain MRI
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MRIMRI
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MRIMRI
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SPECT SCANSPECT SCAN
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PET SCANPET SCAN
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Epilepsy SurgeryEpilepsy Surgery To make sure that it is safeTo make sure that it is safe
Wada testWada test: to study speech and memory: to study speech and memoryNeuropsychological testingNeuropsychological testing: mental functions (IQ, : mental functions (IQ,
memory, attention) and personality assessment memory, attention) and personality assessment Psychological evaluationPsychological evaluationOphthalmologic evaluationOphthalmologic evaluation
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Epilepsy SurgeryEpilepsy Surgery Some cases in which the localization is not Some cases in which the localization is not
clear or where function could be affected will clear or where function could be affected will require INVASIVE ELECTRODESrequire INVASIVE ELECTRODES
Depth electrodesDepth electrodes Subdural electrodesSubdural electrodes
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Subdural ElectrodesSubdural Electrodes
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Types of Epilepsy SurgeryTypes of Epilepsy Surgery
Temporal LobectomyTemporal Lobectomy Extratemporal Extratemporal
ResectionsResections HemispherectomyHemispherectomy Corpus CallosotomyCorpus Callosotomy
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Outcome after epilepsy surgeryOutcome after epilepsy surgery Anterior temporal lobectomyAnterior temporal lobectomy
70-80% seizure free70-80% seizure free Neocortical resectionNeocortical resection
With lesion: 50-80% seizure freeWith lesion: 50-80% seizure free Without lesion: 30-50% seizure freeWithout lesion: 30-50% seizure free
HemispherectomyHemispherectomy Significant improvementSignificant improvement
Corpus CallosotomyCorpus Callosotomy Significant improvement for drop attacksSignificant improvement for drop attacks
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Complications of surgeryComplications of surgery Low rate of Low rate of
complicationscomplications InfectionsInfections BleedingBleeding AnesthesiaAnesthesia Function Function
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Vagus Nerve Stimulator (1997)Vagus Nerve Stimulator (1997) Intractable epilepsy patient without focus or desires Intractable epilepsy patient without focus or desires
interim step before epilepsy surgeryinterim step before epilepsy surgery Goal is to reduce amount/severity of seizures vs. cureGoal is to reduce amount/severity of seizures vs. cure Device surgically implanted in left chest/axilla areaDevice surgically implanted in left chest/axilla area Coils around left vagus nerveCoils around left vagus nerve Stimulation is automatic; patient can additionally Stimulation is automatic; patient can additionally
stimulate device if aura stimulate device if aura
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VNS Therapy VNS Therapy
VNS: <10% seizure free,VNS: <10% seizure free,
30-50% with at least 50% seizure 30-50% with at least 50% seizure decrease, more with lesser improvement; decrease, more with lesser improvement; effects on seizure severity?effects on seizure severity?
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Deep Brain Stimulation (DBS)Deep Brain Stimulation (DBS)
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NeuropaceNeuropace
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ConclusionConclusion-Not all patients with refractory -Not all patients with refractory
epilepsy are surgical candidates.epilepsy are surgical candidates.-Patients with -Patients with FOCAL refractory refractory
epilepsy are candidates for surgery.epilepsy are candidates for surgery.-Multiple steps are required before -Multiple steps are required before
your doctor concludes that you are your doctor concludes that you are a surgical candidate. a surgical candidate.
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ConclusionConclusion
You might be a good surgical You might be a good surgical candidate however a candidate however a RESECTIVE procedure might RESECTIVE procedure might not be possible, due to the not be possible, due to the proximity o the seizure focus proximity o the seizure focus to “eloquent cortex”to “eloquent cortex”
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Thank youThank you