While drugs are the main treatment for epilepsy, there are other options which can be explored if your epilepsy proves resistant to treatment, or if you find drug side effects unacceptable, or if you want to consider other kinds of treatment because, for example, you’re planning to become pregnant. While the more precise use of drugs, or a change of drugs, might solve problems for some, there will always be some people whose epilepsy remains hard to control, who suffer disabling side effects from drugs, or who just dislike having to take regular medication.

These other treatments vary enormously, from the highest of high-tech surgical techniques, to the very specialized high-fat ketogenic diet, to the more homely sounding trained dogs who can give warning of seizures. While some of these treatments may have a limited application, either because they’re not widely available, or because they may only suit certain forms of epilepsy, epilepsy is an area where the latest research is constantly challenging ideas about the condition. Sometimes, what seemed almost impossible yesterday becomes reality today, such as laser surgery for epilepsy. So, although such treatments may not benefit everyone, they may certainly be worth exploring if you find that drugs do not suit you.

Epilepsy surgery
Epilepsy surgery, traditionally the last resort of the person with hard-to-control epilepsy, can seem like a frightening option at first. But, it has aroused new interest and controversy lately as modem neuroimaging techniques make for more accurate diagnosis, while revolutionary electronic and laser methods result in safer surgery. Many doctors now believe that surgery should be used more, and earlier.

Epilepsy surgery is different from drug treatment in that it can actually cure epilepsy, although only a minority of people with epilepsy – around 4-5 per cent – have the type of epilepsy which is currently considered suitable for this treatment. Surgery can be performed if there is an identifiable epileptic zone or abnormality in the brain from which seizures start, something which may be shown on the MRI scan. People may also be considered for surgery if they have frequent, disabling seizures which do not respond to medication, and which are always partial or focal, that is, starting on one side of the brain.

However, new research is expanding the parameters of those considered to be suitable candidates for surgery. For example, a recent study of 2,200 patients in Paris found that mesial temporal lobe epilepsy, which does not respond well to medication but is curable with surgery, is more common than suspected, which means that there may potentially be many thousands of people who would benefit from surgery who are currently not even screened for surgery. Around 80-90 per cent of people with this type of epilepsy, caused by often subtle abnormalities in the brain’s hippocampus, will become seizure-free after surgery.
There is also growing recognition that the earlier surgery is performed, the better the likely outcome for the person, not just directly in terms of seizure control, but indirectly in terms of relationships with others, education, employment prospects and other lifestyle issues. This obviously has particular relevance for children, and it has been found that even young babies can be successfully treated by surgery. An American study of 136 operations performed at the Opportunities Cleveland Clinic Foundation in Cleveland, Ohio, showed that nearly 70 per cent of operations led to complete seizure freedom, with an additional 10-20 per cent resulting in substantial improvement and only rare seizures after the operation. This study, reported in the Annals of Neurology; the official journal of the American Neurological Association, dealt with young children and adolescents who had previously suffered dozens or even hundreds of seizures a day which had proved resistant to multiple trials of anti-epileptic medication.

One reason why surgery may not be more frequently prescribed is the time and the difficulty in assessing patients for surgery. There are only a few centres able to do assessments for surgery in the UK. Many doctors argue that surgery is ultimately more cost-effective than allowing patients to spend a lifetime as consumers of healthcare resources such as anti-epileptic drugs, routine hospital visits and emergency treatment after injury from seizures. People facing the prospect of an operation may well be more concerned with the risks and benefits than the expense, however, so just what are the success rates and dangers of epilepsy surgery? Success rates vary from centre to centre, but, in general, operations on the temporal lobe have the best chance of success -following anterior temporal lobectomy, some 70 per cent of people are seizure-free and 85-90 per cent show worthwhile improvement, although some people may still have auras or take medication according to Epilepsy? by Tom McGowen.

Like any other surgery, epilepsy surgery does have its risks, though the main risks are generally considered to be very low (1-2 per cent according to Epilepsy? by Tom McGowen), and are to do with stroke, paralysis, speech problems, and risks common to all operations such as anaesthetic complication and infection. Candidates for surgery are rigorously screened, and given a battery of exhaustive neuropsychological tests to make sure surgery will not affect vital brain areas, such as language, memory, concentration, motor, visual-spatial and other skills – all particularly important when considering operations within the temporal lobe which is implicated in so many of these functions. Surgery candidates will also undergo other tests such as repeated EEG monitoring, sometimes overnight or longer by videotelemetry, and, rarely, using more invasive electrodes, depth electrodes’ fine silver needles which penetrate the skull to the brain in order to monitor epileptic activity more precisely. CT scans and MRI scans will also be needed. None of this is done quickly, especially as you may have to wait for an appointment at a specialist epilepsy centre, rather than an ordinary hospital. It may be a year or longer before all tests are completed and an operation is carried out.

Epilepsy surgery works by removing the source of the seizures, such as a scar, when it’s known as resective surgery. Alternatively, surgery may involve disconnecting the seizure source (part of the brain from which seizures start) from other parts of the brain {disconnection surgery). This is done by cutting nerve fibres so that seizure activity can no longer travel along the nerve pathways. Disconnection surgery interferes with the spread of a seizure, but doesn’t remove the part of the brain which causes a seizure. New methods of surgery are also becoming available and have aroused a great deal of interest, although like other surgery their use is limited.

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