Epilepsy Surgery: New Frontiers

Epilepsy is a continuing neurological disorder in which brain cells, or neurons, produce irregular electrical discharges, causing the other nearby cells to fire too. Seizures may present in different ways, from staring episodes to strange movements and behaviors (even laughter). 

For most patients, epilepsy can be controlled with medications. However, for those whose seizures cannot be managed with medications, surgical treatments may lead to better outcomes. 

What surgeries treat seizures? 

There are two major types of surgeries to treat seizures: those that require your doctors to locate where in the brain seizures are arising, and those that do not. First, we will talk about how to identify seizure starting points, and then some of the options for treating the type of seizures that come from a specific spot or several spots. Finally, we will review the surgical options for seizures that start from all over the brain at the same time. 

What is sEEG?

Stereoelectroencephalography (sEEG) is a technique for localizing where seizures are generated within the brain. In the past, a large window of skull was opened to lay sensors over the brain’s surface, but now we can insert multiple electrodes (like pieces of angel hair pasta that can sense seizures) into the “neighborhood” within the brain where we believe the seizures are beginning to determine which “house” is starting the party, so to speak. The process captures a 3D image of seizure activity in the brain.

Ochsner uses a special robot that has been designed to put the electrodes exactly where providers want them to go through tiny holes in the skull. Epilepsy doctors then carefully plan the paths before surgery, and the robot guides them to get each sensor in the right spot much faster than could be done in the past. After sEEG placement, seizures are monitored for about two weeks. Once it is determined which “house” is starting the activity, the electrodes will be removed, and treatment options will be discussed. 

What is LASER interstitial thermal therapy?

LASER interstitial thermal therapy (LITT) uses a LASER to cook tissue that causes seizures in the brain. This minimally invasive treatment is for patients whose seizures begin in a small area of the brain that can be safely removed. 

Like sEEG placement, a small hole is drilled in the skull with robot guidance. The LASER fiber or fibers are placed into the area that is responsible for starting the seizures. Then, using MRI to monitor, the LASER is used to disable the seizure onset zone. Most patients can go home after one night in the hospital.

What is responsive neurostimulation (RNS)?

Like a pacemaker, the responsive neurostimulation system (RNS) allows us not only to monitor but also treat seizure onset zones. It consists of a generator or battery that sits in the skull and connects to two electrodes placed in the brain where seizures begin. It is mostly used for patients whose seizures arise in an area that cannot be safely removed, such as the part of the brain that controls speech or the movement of your right hand, or in situations where seizures come equally from both sides of the brain. No brain tissue must be removed to implant this system. 

The system will sense if a seizure is starting, and if so, it will deliver an electrical signal to stop the seizure from spreading. Patients cannot feel the signal being delivered. The skull generator will store information about the seizures, which can be downloaded wirelessly to a laptop to share with an epilepsy doctor.

What is deep brain stimulation?

Deep brain stimulation (DBS) is another stimulator that can be used to treat seizures. Historically used for treating tremors and stiffness, it can now be put in a different part of the brain to help treat seizures with small regular electrical impulses. Like RNS, the system consists of electrodes that are placed in the brain that then connect via extension wires to a generator in the chest. 

What is a temporal lobectomy?

A well-established approach for treating seizures that begin in the middle, lower portion of the brain is temporal lobectomy, an open surgical procedure in which areas are removed where patients’ seizures begin. This procedure is an excellent option for people whose seizures arise not only from the deeper portion of the temporal lobe but also from surrounding outer brain regions. 

What if seizures cannot be localized?

Though it is preferred to be able to identify where seizures are starting, some patients are not able to go through sEEG monitoring or have seizures where the whole brain starts at the same time. These patients may also qualify for surgery, and studies are actively assessing whether more options might be available in the future. 

What is Vagus nerve stimulation?

Vagus nerve stimulation (VNS) is a procedure to treat epilepsy with surgery that does not require a surgeon to enter the brain. In this surgery, a small flexible set of leads is placed around a nerve in the neck. This connects to a pacemaker-like battery pack in the chest and provides mild electrical stimulation throughout the day to help break up seizure cycles in the brain. About 50% of patients have about a 50% improvement in seizure frequency and severity.

Because everyone’s seizures are unique, there is no “one-size-fits-all” treatment for epilepsy. Ochsner’s epilepsy program aims to provide state-of-the-art, innovative medical and surgical care for patients with epilepsy.