About the e-pilepsy project

e-pilepsy is a pan European project, with the primary aim of improving the awareness and accessibility of surgery for epilepsy across different countries.

Epilepsy is a condition whereby individuals are prone to recurrent epileptic seizures. Although many gain seizure control through medication some with persistent seizures are suitable for surgery.

Epilepsy surgery is an established treatment in the management of carefully selected individuals with drug resistant focal epilepsy. Individuals are evaluated to determine whether a single area of the brain is causing seizures which could be removed without causing further problems, potentially curing the epilepsy.

e-pilepsy home What is epilepsy?

What is epilepsy?

We can all have a seizure and about 1 in 20 people will have a seizure in their life. However, in some people either the balance of inhibition and excitation is disturbed throughout the brain leading to the occurrence of repeated generalised seizures, or the balance is disturbed in one part of the brain leading to repeated focal seizures.

This disturbance may be caused by a variety of reasons, including:

A person’s genes

Damage to a part of the brain from birth

A head injury, stroke or brain infection

A part of the brain not developing properly, due to a brain tumour or certain drugs/alcohol.

Epilepsy is not uncommon. 1 in 30 people will develop epilepsy but, at any one time, less than 1 in 100 of the population has epilepsy because many people recover. About one third of people with epilepsy are not controlled with anti-epileptic drugs. For these people, other treatments are needed.

About the project

e-pilepsy is a pan-European project with the primary aim of improving awareness and accessibility of surgery for epilepsy across different countries.

Epilepsy surgery is an established treatment in the management of individuals with drug-resistant focal epilepsy. However there is still a lack of awareness of the likely candidates and possible benefits of epilepsy surgery amongst doctors and patients.

e-pilepsy has established a consortium of 13 centres as associate partners, with a further 15 collaborating centres to drive this project. The primary expected outcome of the project is to increase the number and proportion of European children and adults cured of their refractory epilepsy by improving delivery of optimal epilepsy surgery throughout Europe.

Aspects of e-pilepsy include:

improving accessibility of information

facilitation of referral for assessment

improving tools for assessment

improving analysis of investigations as well as the training across different sites of individuals to be involved in assessment for epilepsy surgery.

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What is epilepsy surgery?

If anti-epileptic medications do not control epilepsy seizures, brain surgery can be considered for some patients.

The most commonly performed type of brain surgery is called Resective Brain Surgery. Resective surgery for epilepsy is used to remove the part of the brain that is causing the seizures. This means that it can only be used for people where the seizures start in one area of the brain. When seizures start in one part of the brain only, this is called Focal Epilepsy.

There are different kinds of Resective Brain Surgery that occur in different parts of the brain, depending on where the seizures start. Some surgeries mainly involve removing a lesion as seen on the MRI - this is called a lesionectomy. Other surgeries involve larger parts of the brain. They may involve all or most of one of the lobes of the brain. The brain is divided into four paired sections:

The frontal

Parietal

Occipital

Temporal lobes

Temporal lobe surgery

The most common type of Resective Brain Surgery in adult epilepsy is performed in the temporal lobe. The temporal lobe is located on either side of the brain just above the ear. It plays an important role in language, hearing and memory, and many people with temporal lobe epilepsy therefore also suffer particularly from memory problems.

A temporal lobe resection means that brain tissue in the temporal lobe is resected, or cut away, to remove the seizure focus. The anterior (front) part of the temporal lobe and the deep part and mesial (deep middle) portions of the temporal lobe are the areas most often involved. The deep portions contain a structure called the hippocampus, which is involved in forming memories.

A temporal lobe resection requires exposing an area of the brain using a procedure called a craniotomy. After the patient is put to sleep with anaesthesia, the surgeon makes an incision in the scalp, removes a piece of bone and pulls back a section of the dura, the tough membrane that covers the brain. This creates an opening in which the surgeon inserts special instruments for removing the brain tissue. Surgical microscopes are also used to give the surgeon a magnified view of the area of the brain involved. The surgeon utilises information gathered during the pre-operative evaluation - as well as during surgery - to define, or map out, the route to the correct area of the temporal lobe. After the brain tissue is removed, the dura and bone are fixed back into place, and the scalp is sutured up using stitches or staples.

Other surgical procedures

Another area of surgical intervention is implantation of brain stimulators. Stimulators introduced into the brain are currently being investigated. In general, they can be considered in people where there are no resective surgery options. Deep Brain Stimulation (DBS) is a surgical procedure by which leads that have been implanted into specifically targeted areas in the brain deliver controlled electrical stimulation. This procedure may, in selected people, ameliorate seizures.

Much more widely used are Vagal Nerve Stimulators. These are small devices, similar to a cardiac pacemaker, which are implanted under the skin below the left collarbone. This is connected via a lead to the vagus nerve in the left side of the neck. The VNS stimulates the vagus nerve at intervals to reduce the frequency and intensity of seizures.

How surgery works

Epilepsy surgery can work in 3 different ways:

By removing the 'bad' part of the brain

Removing the connection of the ‘bad’ part to the other brain areas

Implanting an electrical stimulator that, through electrical stimulation, reduces the excitability of the ‘bad’ part(s) of the brain.

The brain consists of 100 billion nerve cells with trillions of connections. Seizures may arise in a small area of the brain but then, through these many connections, spread to other areas and eventually to the entire brain.

Epilepsy surgery works by identifying the main area from which seizures arise and removing that area (provided it is not critical for important functions such as speech and movement). This is termed ‘curative, resective surgery’.

Resective surgery is not always successful because it is not always possible to localise where the seizures arise or, once one area of brain is removed, the seizures start to arise from a different area. Sometimes it is not possible to remove the area from which seizures arise, because it is in an area that is crucial for the brain to function.

The surgeon may then decide instead to cut the connections by which the seizure spreads (termed ‘subpial transection’). This operation is generally far less successful.

What you need to take into consideration

If the seizures arise from multiple brain areas (multifocal seizures) or from the whole brain (generalised seizures), then resective surgery is not usually possible. Instead, operations are used with the aim of improving or lessening the seizures with a much lower chance of stopping the seizures.

The second most common focal epilepsy in adults is frontal lobe epilepsy. The frontal lobes are the largest lobes of the brain and some important functions of the frontal lobes are motor function of the body, including speech and short-term memory and attention. Some areas of the frontal lobes are also not well understood and participate in more complex human behaviour and emotion. Particularly if no lesion is seen on the MRI, surgeries in the frontal lobe often require intracranial EEG electrodes placed onto and/or into the brain. These electrodes are placed in the operating theatre, and people then come to the epilepsy-mentoring unit to get the electrodes connected to the EEG machine and to record the seizures.

FIGURE; right frontal lobe epilepsy, showing multiple deep electrodes placed to find where seizures start. The EEG tracing shows the start of a seizure from the middle deep frontal lobe. The arrow points to where the seizure was recorded.

Figure: left frontal lobe epilepsy. The figure shows a computer reconstruction of a patient’s MRI, with the left frontal lobe outlined. On the right hand side the same brain is shown after a grid of electrodes has been placed onto the brain to determine seizure onset and important functions.

Post-surgery

A life without seizures can take some adjustment, not only for the individual but also those around them. Families and individuals undergoing the surgery may need additional support to adjust to this. Medication will continue for at least a period, and there is no guarantee that it will be weaned with success. About 50% of individuals are able to wean medication after surgery if seizure free.

Side Effects

One of the side effects of epilepsy surgery in the temporal lobe may be the weakening of memory. How much this affects the patient depends on many factors including whether there is already significant damage involving the hippocampus and how well the memory was working before surgery. Other people may experience some difficulties finding the right word, or have mood problems after surgery. Understanding who’s most likely to experience these side effects is important, so they can be counselled before they consider surgery. The risks of surgery have to be balanced against the risks of continued uncontrolled seizures.

It is important to realise that brain surgery for epilepsy may not always lead to a complete cure. In fact overall probably only half of all people treated will become completely seizure free. Studies have shown that it also very much depends where seizures arise from and whether there is a clear lesion visible on the brain MRI causing seizures that can be completely removed.

In temporal lobe epilepsy, particularly when there is scarring of the hippocampus, up to two thirds of all people can enjoy seizure freedom after the surgery.