Role of surgery in the intractable epilepsy By Dr. Mohammed Amin Alkamaly

1. Role of surgery in the intractable epilepsyBy Dr. Mohammed AminAlkamaly

2. Over view • Epilepsy remains one of the most common neurologic disorders affecting both adults and children . •  Approximately 30% of patients with epilepsy are considered "medically intractable" meaning that they continue to have seizures despite medical therapy. It is in this group of patients that seizures have the most significant impact on quality of life( qof) including relationships with family, friends and co-workers, and the ability to work and to drive

3. In the past 10 years, epilepsy surgery has increasingly been recognized as a viable treatment for patients with medically refractory seizures

4. What is the intractable epilepsy ? • "Medically intractable" patients by definition have failed at least two antiepileptic medications, but patients have often been trialed on multiple medications for an unduly long period of time

5. epidemilogy • In the United States, approximately 3 million people have been diagnosed with epilepsy. Half of these patients have partial seizures, and in 30% seizures are not controlled adequately with antiepileptic drugs (AEDs). • A conservative estimate is that one half of patients with medically intractable epilepsy are potential candidates for epilepsy surgery

6. To determine if a patient is a candidate for epilepsy surgery, an extensive evaluation is undertaken, including video-EEG telemetry, anatomical (MRI) and functional (positron emission tomography (PET) or single photon emission computerized tomography (SPECT) imaging) and neuropsychological testing intracranial-EEG team work neurosurgonneuropsycatraic radiologist

7. Type of surgery

8. The type of surgery is based on the epileptic syndrome, imaging and electrophysiological findings

9. Outcomes •   Outcomes following resective surgery for the treatment of epilepsy have markedly improved over the last few decades. For patients with temporal lobe epilepsy, it is now widely accepted that surgery is superior to prolonged medical therapy, following the publication of the results of a randomized clinical trial in 2001. Frequently with this type of surgery, the proportion of properly selected patients who are seizure free after surgery can be above 70%.  • While the other types of resective surgery are less likely to have a seizure free outcome, the numbers are proportionately better than medical therapy alone.  Seizure free outcomes range from 30- 70% for extra temporal lobe epilepsy syndromes.

10. Disconnective procedures can improve the patient's quality of life by decreasing the frequency and intensity of the seizures even in generalized type of epilepsy • One other type of surgical procedure available is the implantation of a vagal nerve stimulator (VNS).  The VNS was FDA approved in 1997 and has been found to significantly lessen the intensity and frequency of seizures greater than 50% in over half the patients that are treated. It is indicated for patients who are medically intractable and are not candidates for other types of surgical intervention.

11. prognosis Certain readily definable, surgically remediable syndromes are easily identified, have an excellent prognosis for seizure control, and have minimal surgical morbidity. Postoperatively, many patients with these syndromes have improved quality of life (QOL), improved cognitive, psychosocial, and occupational outcome. In children with catastrophic epilepsy due to diffuse hemispheric syndromes, early surgical intervention stops seizures and reverses the cognitive decline so that these patients can develop normally, eventually leading relatively normal lives

12. Difference between adult and child • In children the epilepsy surgery has additional importance because it can improve the brain development and maturation by stop the harmful effects of abormaldischage on neurons and body • Determan the intractable seziur in childern easier because the high rhythm of fits compar with adult

13. In addition, the epileptogenic process itself produces dysfunction with adverse consequences on cognition and mood, which can be irreversible, particularly in children. – • side effect with medications

14. Importance • The studies underscore the fact that patients with partial epilepsy who do not become seizure free after trials with 2 first-line AEDs are less likely to achieve seizure freedom with additional AED trials. • In this regard, early identification of these patients with surgically remediable epilepsy is crucial, since the rate of seizure-free surgical outcome ranges from 70-80% in well-selected cases.

15. Future Options our • The future of surgical epilepsy is likely to continue to grow since the majority of patients who are potential surgical candidates have not been evaluated and treated.  It is estimated that less than 3% of patients who would benefit from a surgery actually undergo treatment. With improved awareness of the benefits of surgery, improvements in neuroimaging to identify abnormal brain areas, and improved technologies for intervention, it is likely that surgery will be the option of choice for those patients who suffer the most from this disease