Lesionectomy for Epilepsy

Overview

Approximately 20 percent of people with epilepsy cannot adequately control their seizures with anti-epileptic drugs (AEDs). Other people experience serious side effects from AEDs that impact their quality of life. Some of these people may be candidates for surgery.

Lesionectomy is a type of brain surgery used to treat people with epilepsy. The goal of lesionectomy surgery is to remove the seizure focus while preserving vital functions such as speech, sensation, movement, and memory. Lesions in the brain may be caused by a tumor, malformed blood vessels, scar tissue from an injury of infection, or a pocket of tissue swollen with blood (hematoma). Brain lesions cause epilepsy in as many as 30 percent of people whose seizures are not controlled by AEDs.

Not everyone with intractable epilepsy is a good candidate for lesionectomy. Lesionectomy is most effective in people whose seizures can be traced to a defined lesion. In addition, it must be possible to remove the lesion without disrupting important brain functions such as memory, communication, and hearing. In order to qualify for lesionectomy, you must have tried several different AEDs for significant periods of time. Finally, you and your doctors must agree that the benefits you might gain by undergoing the surgery outweigh the risks of performing the procedure.

What does it involve?
In order to decide whether you are a good candidate for lesionectomy, your neurologist will perform extensive testing. The pre-surgical evaluation tests may include seizure monitoring, magnetic resonance imaging (MRI) scans, positron emission tomography (PET) scans, magnetoencephalography (MEG) tests, Wada tests, and electroencephalography (EEG) monitoring. The EEG monitoring may be performed externally or invasively, using electrodes that are placed inside your skull. Pre-surgical evaluation is very thorough in order to pinpoint the lesion and ensure that it is the source of your seizures. You and your doctor should decide together whether a lesionectomy may be right for you. Do not be afraid to ask questions about any aspect of the surgery or recovery.

You will be given instructions to stop eating a few hours or possibly the night before surgery. When you arrive at the hospital, vital signs will be taken, and blood will be drawn for testing. A portion of your head may be shaved. When it is time for the surgery, you will receive an intravenous (IV) line and anesthetic medication.

During the lesionectomy, the neurosurgeon will make an incision in your scalp and retract a flap of skin. The neurosurgeon will then remove a section of your skull in a procedure known as a craniotomy. Next, the neurosurgeon will retract a section of the dura mater, the tough outer covering of the brain. Viewing your brain through a surgical microscope, the neurosurgeon will insert instruments. For a portion of the surgery, you may be put into a sedated, twilight state, just conscious enough to respond to questions. Doctors or nurses may ask you to count, describe images, or other tasks in order to help the neurosurgeon pinpoint which sections of your brain are responsible for which functions. The neurosurgeon will cut away the lesion. They may also remove a narrow margin of healthy brain tissue around the lesion; this procedure is called corticectomy. When the neurosurgeon is finished performing the lesionectomy, they will close the dura mater, fix the skull back in place, and finally close your scalp with staples or stitches.

You can expect to stay in the hospital for four to six days after receiving lesionectomy surgery. Once you return home, it will take six to eight weeks to recover completely from surgery and resume work, school, or other normal activities. Your hair will hide the scar when it grows back.

You will likely continue taking your AEDs after surgery until your neurologist establishes how effective the surgery was in controlling your seizures. You may eventually be able to reduce or stop taking your medications. You should never suddenly stop taking an AED. Always consult your neurologist for a plan to taper off gradually in order to avoid withdrawal.

Intended Outcomes
Lesionectomy may help eliminate your seizures. After lesionectomy, you may be able to reduce or stop taking AEDs.
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Results
Approximately 50 to 90 percent of those who undergo lesionectomy become seizure-free after surgery.

Constraints
Lesionectomy may not be successful at eliminating your seizures.

Any surgery carries risks including blood clots, blood loss, infection, breathing problems, reactions to medication, and heart attack or stroke during the surgery.

Lesionectomy surgery can cause pain and swelling, and you will most likely need pain medication for some weeks during recovery. Other temporary side effects may include paralysis, personality change, fatigue, depression, headaches, numbness in your scalp, nausea, and trouble remembering or speaking some words.

Possible complications of lesionectomy include swelling in the brain and damage to healthy brain tissue. Even if seizures are eliminated, you may continue to experience auras, the sensations that signal the beginning of a seizure.

Some people become anxious if they experience a seizure after surgery. A seizure after surgery does not indicate that the surgery was unsuccessful. It may be necessary to examine seizure triggers or adjust medication in order to reestablish control.

Even if surgery is successful at completely controlling seizures, some people have trouble adjusting to life without seizures. Although it is a positive change in many ways, it can create stress and put pressure on interpersonal relationships. Seek support or therapy if you find yourself becoming depressed or anxious due to changes in life after surgery.