Epilepsy is a chronic condition in which patients experience recurrent seizures without any provoking cause because of chronic underlying brain etiology. Seizure is just a symptom of epilepsy disorder. Epilepsies can be associated with brain malformations, tumours, previous ischemic insults, infection, birth related injuries etc. Very few patients can have genetic component as well for epilepsy.
There are major three types of epilepsies. In first type, no cause can be found out irrespective of all the tests and investigations. These are called as idiopathic one. In other one, there is some obvious cause in brain like tumor or malformation or previous birth injury related changes responsible for epilepsy. These are called as symptomatic epilepsy, which are treatable. The third type is actually a grey area between these where we strongly suspect that there is should be some cause, but with present investigations we cannot find it. These are labelled as cryptogenic one, which should be investigated further.
Single episode of seizure does not constitute epilepsy and hence most of the times you don’t need any treatment. However once epilepsy is diagnosed with careful clinical history and EEG by experienced neurologist or physician, standard modality of treatment is antiepileptic medications. However, if seizures doesn’t respond to antiepileptic medications i.e. they become drug resistant, they can be evaluated and successfully treated with surgery. If surgery does not appear to be feasible after evaluation is complete, such patients can be treated with palliative procedures.
Generally, patient is prescribed one drug at first and dose is escalated gradually over weeks to control the seizures. 50% of patients benefits from single drug only and epilepsy is controlled. In those, which continue to have seizures after first drug, second drug is started which generally relieves another 15% patients. However, if patient continues to have seizures even after two drugs, the chances of controlling seizures with third drug is minimal. Hence, patients who continue to have seizure after trying two drugs for adequate time, are labelled as drug resistant. Generally, idiopathic epilepsies are well controlled on one medication, but symptomatic and cryptogenic epilepsies, which have something abnormal in their brain do not respond to medications and mostly becomes drug resistant.
In 35 from 100 patients diagnosed to have epilepsy, drugs cannot control epilepsy. Most of the time, these patients have something visibly abnormal in their brain. So, logically if we can deal with abnormality which is visible on MRI brain, we can practically cure epilepsy. Surgery for epilepsy are some surgeries on brain, where we remove or alter the abnormal currents in brain circuits so as to stop/alter/modify the seizures and improve the quality of life of person affected with epilepsy.
If your seizures are controlled on one or two drugs, then there is no need for surgery. However, when you have to take more than two medications and you continue to have seizures, surgery is rational choice for following reasons.
a. Seizures are bad to experience and you lose many privileges in life like employment, driving, swimming and sports. Adding further drug is not going to control your seizures. You will be under constant threat of having seizure and will be dependent on companion for routine activities.
b. 3-5 patients out of 100 die with epilepsy every year. Thus, 15 out of 100 patients will die in next five years from epilepsy. However chances of dying from epilepsy surgery is just 2 % and its one time risk.
c. Epilepsy medications have many side effects which include bone problems, weight gain, mood problems, cognitive decline and loss of memory. More medications you take, more chances of cognitive decline over time period.
d. Also, with every seizure, some neurons die of ischemia and capacity of brain goes down. It’s a slow process of memory and cognitive decline.
e. Even financially, if you are on two medications, your monthly maintenance comes to around 5000/ month i.e. .60,000 annually. The cost of epilepsy surgery is close with all investigations, hospitalization is close to 2 lakhs.
Once you are categorized as drug resistant epilepsy and being considered for epilepsy surgery, you will have to undergo three major steps. Pre-surgical evaluation followed by a consensus decision and finally surgery. In pre-surgical evaluation, we decide the exact parts of your brain which is responsible for this epilepsy with various tests, clinical evaluations etc. And a team of doctor specialists from various related fields meet together to discuss and reach a consensus about the type of surgery you will need. A final plan is decided in the multidisciplinary meeting.
Pre-surgical evaluation consist of three main domains. Most important is video EEG followed by investigations like MRI, PET scan, SPECT scan. This MRI scan done here is not the routine MRI but customized scan which will depend on your video EEG recordings. Neuropsychological evaluation is also a crucial part of presurgical evaluation which provide important insight about the localization and possible problems you will be having after surgery. Once all these investigations are ready, it is generally discussed in meetings to reach a consensus about the plan.
Video EEG is nothing but simultaneous recording of EEG along with video camera focused on you all the time. You will be admitted and EEG leads will be attached to you. You will be under camera for 24 hours while your EEG on. When you will have seizure, it will record the exact movements you do during your seizure activity and simultaneous EEG recordings. This will give us the exact idea of the area of your brain responsible for producing these seizures. Generally, we record 3-10 episodes of seizure and hence patients generally stay for 5-7 days in hospital. We generally stop your drugs so that more seizures can be obtained in short time. It is safe as you are having seizures in controlled environment of hospital, equipped with doctors and nurses all the time. During the same hospitalization, you will undergo neuropsychological evaluation and MRI and PET testing as and when required. Plan is finalized once at the end of your hospitalization.
Approximate cost of hospitalization and pre-surgical evaluation is approximately 70 thousands and further cost of surgical treatment is approximately 1.5 lac. making total of 2.25 lac. However it varies from case to case basis and in some patients these costs can be brought down to almost all inclusive 1.5 lac.
Epilepsy surgeries are mainly of two types. In patients where we find a small, focal brain area responsible for epilepsy, we go for resection of that area. These surgeries are called curative surgeries where once that area is removed; patient will be mostly free of epilepsy. However, there is a group of patients in which a large area is responsible or we could not define a small area or removing complete area is not feasible; surgeries are meant to just reduce seizure frequency and improve quality of life. These surgeries are called palliative surgeries.
Chances of seizure control depend on many variables and varies between 50-90%. If there is tumor or malformation or localized area which could be removed completely, then 90% patient achieves freedom from epilepsy. However, outcome is in the magnitude of 50% with palliative surgeries. Outcome typically depends on the responsible pathology. Overall, 60% patients definitely better with epilepsy surgery over long term. If MRI shows some lesion which could be removed, then 9 out of 10 people can achieve seizure freedom and almost 6 out of 10 patients can be off medicine.
Complications are very infrequent in epilepsy surgery with major complications like motor deficits, language deficits, vegetative states and disabilities in 3-5% magnitude. Other treatable complications like infections, prolonged hospitalizations, transient deficits, speech problems, mood problems, visual field deficits are common and do not alter the normal daily life. Overall, epilepsy surgery is safe surgery and it improves quality of life of many patients and their care takers significantly.
For most of the procedures, patient stays for one week in hospital after surgery. It depends upon the type of surgery patient is undergoing. If it is a major surgery, then patient may spend 3-5 days in intensive care units and another week in ward followed by rehabilitation services. Palliative surgeries take longer durations. It also depends on patient’s preoperative condition.
When a patient who is doing job undergoes epilepsy surgery, we typically advise a two weeks period for complete recovery and returning back to original job. However it may depend upon the nature of job and surgery done.
If you are advised epilepsy surgery, then you must be taking at least two drugs and mostly failed another two cheaper drugs like phenytoin sodium (EPTOIN) and phenobarbitone ( GARDINAL). The monthly expenditure of newer epilepsy drugs is nearly around 3000-5000 INR. Apart from this, loss of job and expenses of maintaining a constant companion accounts further. The cost of epilepsy surgery in our unit is just 2-2.5 lac depending on type of hospitalization. It can be further brought down if you qualify for financial support from many trust across India which funds epilepsy surgery.