Dr. Prithika Chary is the senior most neurologist at Kauvery Hospital having joined at its inception in 2012 as its first neurologist.

She has specialised training & expertise in the management of various brain disorders, especially epilepsy, & her team has done over 50 epilepsy surgeries with good outcomes since 1998.

She is in active neurological practice in Chennai city since 1974. Her medical training includes MBBS – 1971, MD – 1974, DM (Neurology) – 1978, PhD – 1981 & MCh (Neurosurgery) – 1990.

Epilepsy Surgery – The Hope and the Hype

Epilepsy is a brain disorder characterized by recurrent, unprovoked, spontaneous seizures. It occurs due to an electrochemical disturbance in the nerve cells of the brain. It is a common disorder, being present in 1 in 150 of the population, irrespective of geography or economic status. It does seem to be more however in poor resource countries where general health care is not adequate, thus making the population more prone to develop epilepsy.

There are many ways in which epilepsy can manifest, but we are going to focus in this article on a type of epilepsy called temporal lobe epilepsy. The origin of the seizure is in the temporal lobe (see image) and the symptoms are peculiar to this type of epilepsy. It is also commonly nonresponsive to drug treatment, which is the mainstay of antiepileptic treatment.

It is very often associated with scarring or other abnormality and is the cause of difficult-to-treat epilepsy. It is also the most suitable type of epilepsy which can be successfully treated with resective epilepsy surgery.

Epilepsy surgery in carefully evaluated and selected patients is almost a cure and this has a tremendous impact on the quality of life of drug-resistant seizures with 2-8 seizures occurring per month despite 2 or more antiepileptic drugs. In these patients, when the abnormal seizure-generating brain is resected, not only do the seizures reduce or stop completely, the secondary damaging effect on the rest of the brain is minimized or removed altogether.

Given below is a poem describing how a patient with temporal lobe epilepsy feels during his/her seizure.

What is this?
This fear in my heart, this churning in my gut
Haven’t I been here before?
Did you say something?
What are those sounds I hear?
Ah! Now my head spins & my eyes blur, & I know not where I am.

“Oh dear” says Mum “not again”
Holding me in her arms, she says
“What I see makes you lose all your charms
You chew & you twitch
Your personality makes a switch
This bizarre, wandering, confused creature is not you
You rub your hands, you moan & groan
Thank God, this is only for a while
Then you start to smile”
Slowly, surely as precisely as it began
The seizure stops & fades.

Normal again, I lay myself down
I am awake, I am alive, but there is no control
I wait & fear one more again
While Mum in dismay
Watches me lovingly, she is sad
Fearing & feeling bad
That another is not far away.

Illustrative Case

Way back in the year 2000, a young lady staggered into my consultation room, clinging to her mother for support as she was drowsy and unsteady.

Her birth and initial development were normal, and from the age of 13 years till her present age of 34 years, she suffered from recurrent seizures which were still around 8 per month despite her being on 5 antiepileptic drugs, which made her cognitively dull, drowsy and unsteady. She knew how to play the piano and would teach this to children when she felt well enough to do so. Her quality of life was severely impaired – failed marriage, no friends, could not go out much, injuries due to fall after a seizure, dependent on her parents for many activities, unable to go to school, etc.

After evaluating her for possible epilepsy surgery (studying her clinical seizure in detail, prolonged video EEG monitoring, special MRI and functional studies, neuropsychological evaluation and evaluation for general health fitness for surgery) the diagnosis was mesial temporal sclerosis (a scarring lesion) localised to one side of the brain. We took her up for a resective surgery called amygdalohippocampectomy and anterior temporal lobectomy.

In the immediate postoperative period, she developed double vision on looking to the side of the surgery which disappeared in a couple of months.

Her drugs were slowly reduced from 5 drugs in heavy doses to 2 drugs in moderate optimum doses.

She was no longer dizzy, drowsy and unsteady. Her cognition was better and she had no seizures at all in the first 3 months.

A year and a half went by and still no seizures.

She went alone to London in 2002, lived by herself and underwent training to be a teacher.

All was well with no seizures. Christmas of 2003, emboldened by not having seizures, she had a couple of drinks to celebrate and had a seizure requiring some increase in the dosage of drugs.

Since then, she has had occasional minimal spells of disorientation, almost always triggered by sleep deprivation, skipping medication or stress.

She is still on one drug in a minimal dose and today lives alone, drives her own car, swims regularly and takes care of her mother with Alzheimer’s disease.

Epilepsy Surgery – The Hope

In patients with difficult-to-treat epilepsy, especially temporal lobe epilepsy, results of resective surgery are very heartening as illustrated in the case above.

All patients may not achieve total seizure freedom like the above person but there will be a definite reduction in the number and severity of seizures and reduction in drugs.

If a person has more than 2 seizures a month, despite 2 or more antiseizure drugs for more than 2 years, they should ask their neurologist for a presurgical evaluation (careful study of the clinical pattern of the seizure, prolonged video EEG – video and EEG are time synched so we can localize the seizure, special epilepsy protocol MRI, functional studies like FDGPET and SPECT and neuropsychological evaluation for assessing language localisation and any comorbid psychiatric disturbances).

Epilepsy Surgery – The Hype

Many patients get worried that brain tissue and not a tumour is removed in this surgery. The maxim is “No brain is better than bad a brain.” which means the brain tissue removed is scarred and malfunctioning brain.

The other concern is it is a major brain surgery, but today in expert hands neurosurgery has advanced to be safe and accurate.

The belief that drugs will no longer be necessary after epilepsy surgery is also a myth. Often, drugs are gradually reduced but not stopped in the first year, and thereafter titrated according to the patient’s progress. As highlighted in the above patient, drugs may even be needed life-long, but in moderate doses to maintain seizure freedom.

This article only gives a very basic introduction to epilepsy surgery and its scope. For more information, ask your neurologist/neurosurgeon.