However, there are also many people with drug-refractory epilepsy who might benefit from surgery but are not considered or assessed. In the UK, this equates to approximately 450 patients per year the number of operations performed equals the number of emergent new cases. 3Ībout 1.5% of people newly diagnosed with epilepsy may eventually require epilepsy surgery. 2 Attaining seizure freedom is also associated with reduced mortality, for example, from sudden unexpected death in epilepsy. 1 Surgical treatment of refractory temporal lobe epilepsy improves both the seizure outcome (58% seizure free) and the quality of life, compared with optimal medical management (8% seizure free). Refractory epilepsy is the failure to achieve sustained seizure freedom despite adequate trials of two tolerated, appropriately chosen and used anti-epileptic drug schedules, either as monotherapy or in combination. The pre-surgical investigative pathway aims to inform this process by localising the epileptogenic zone, eloquent cortex, and major white matter tracts. The outcome of surgery typically represents a balance between seizure control and post-operative deficit. Surgical success may be defined as the complete cessation of seizures without post-operative cognitive, psychiatric or neurological dysfunction. However, in those 30%–40% whose seizures continue despite medication, clinicians should consider other options, such as epilepsy surgery, vagus nerve stimulation or ketogenic diet. Nevertheless, surgery for epilepsy is under-used and should be considered for all patients with refractory focal epilepsy in whom two or three anti-epileptic medications have been ineffective.Īpproximately 60%–70% of people with focal epilepsy become seizure free with medication. Lower rates of seizure freedom are expected in people with extra-temporal lobe foci, focal-to-bilateral tonic-clonic seizures, normal structural imaging, psychiatric co-morbidity and learning disability. The best outcomes are in those with an electro-clinically concordant structural lesion on MRI (60%–70% seizure freedom). This entails optimal imaging, prolonged video-electroencephalogram (EEG) recordings, and neuropsychological and psychiatric assessments some patients may then require nuclear medicine imaging and intracranial EEG recording. Pre-surgical evaluation aims to identify the epileptogenic zone and to prevent post-operative neurological and cognitive deficits. Epilepsy surgery encompasses curative resective procedures, palliative techniques such as corpus callosotomy and implantation of stimulation devices. Epilepsy surgery offers the chance of seizure remission for the 30%–40% of patients with focal epilepsy whose seizures continue despite anti-epileptic medications.
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