Neurology - Epilepsy Surgery

This leaflet will give you information about epilepsy surgery at Salford Royal Hospital.

If you have any questions after reading this leaflet, please feel free to contact the Epilepsy Surgery Team.

Useful contacts

Your Neurologist
Name:
Telephone:

Your Neuropsychologist
Name:
Telephone:

Your Epilepsy Specialist Nurse
Name:
Telephone:

Your Neurosurgeon
Name:
Telephone:
 

What is epilepsy surgery, and why is it relevant to me?

You have been given this leaflet because your Neurologist thinks that surgery might be the right treatment for you.

Epilepsy surgery is a type of brain surgery. It can be used to treat some types of epilepsy. It involves removing areas of the brain which are causing seizures.

The goal of this surgery varies from patient to patient. For most patients, we hope to stop the seizures from occurring.

In other cases, we only expect to make them less frequent or less severe.

Epilepsy surgery is not for everyone with epilepsy. We may offer you surgery if your tablets do not control your seizures.

You can only have surgery if:

• Your seizures are starting in a particular area of your brain
• We can operate on that part of your brain safely

Finding out if you can have surgery

To decide if you can have surgery, we do several tests. To have all the tests which you need usually takes several months.

These tests will show if your epilepsy is caused by an area of your brain which we can remove safely.

You will need to come to hospital for all the tests. For some tests you will need to stay in hospital.

What happens next?

1.    An appointment will be made with the epilepsy neurologist and you will have some investigations, which are described below.
2.    You will have an MRI scan and an admission for Video Telemetry and neuropsychological tests
3.    We discuss these test results at the Multi-Disciplinary Team (MDT) meeting and decide if you might be able to have surgery.

This process takes around 3 months.

4.    The MDT may recommend surgery on the basis of the information available, or may decide that surgery is unlikely to benefit your epilepsy. The MDT may also recommend further tests before a decision can be made. Your neurologist will write to you or meet with you to discuss the MDT decision.
5.    If you undergo further tests, we will discuss these results at the MDT meeting and then decide if surgery is appropriate for you. If surgery is an option, your neurologist will meet with you to discuss the risks and benefits.

This process takes between 3 and 9 months.

6.    If you decide to proceed with surgery, an appointment will be made with your neurosurgeon. A pre-operative check will need to be conducted before any surgery is confirmed.
7.    Surgery takes place.

This process takes between 9-18 months.

The Epilepsy Surgery Team

This includes your Neurologist, Neurosurgeon, Neuropsychologist, Epilepsy Specialist Nurse, EEG team, Radiologist, Neuropsychiatrist, and sometimes other doctors and medical staff who carry out your tests.

The Neurologist is a doctor who treats problems with the brain and nerves.

The Neuropsychologist helps with the psychological aspects of your epilepsy, including your memory and emotions.

The Neurosurgeon is a surgeon who operates on the brain and spine.

The Epilepsy Specialist Nurse can advise you regarding the management of your seizures and their impact on your lifestyle. The nurse is a useful contact for questions regarding your epilepsy and surgery.

The Tests

Before you and the epilepsy surgery team can decide if epilepsy surgery is likely to be of benefit, the team need to do tests to investigate where your seizures are starting in the brain; what areas of your brain are affected by your seizures; how your seizures affect you (for example, memory problems or stress) and if you are likely to be at risk of other problems after surgery.

The following is a list of tests that you may be asked to undergo.

You may not need to undergo all these tests as some are only necessary if the results of other tests suggest that further investigations are needed.

Magnetic Resonance Imaging (MRI)

An MRI scan uses magnetic waves to create images of your brain. This can show if there is an area of your brain which may be causing your seizures. You will lie inside a large tube whilst the scanner takes pictures. It may take up to an hour.

An MRI scan is harmless and painless. The scanner can be noisy and some people with claustrophobia may find the experience of being in the tube distressing, in which case we would discuss ways to help with this, such as relaxation exercises or taking an anti-anxiety tablet before the scan.

Electroencephalogram (EEG)

An EEG can show which part of your brain is causing your seizures. During an EEG, electrodes (leads) are attached to your scalp with special glue. These leads are then connected to an EEG machine.

The machine records the electrical activity of the brain. The test will take about an hour. The test is harmless and painless.

EEG Video-Telemetry

This test helps us to investigate what your seizures look like, and which areas of the brain are involved when you have seizures.

During video telemetry, you will stay in hospital for five days. You will have EEG leads attached to your scalp.

Video cameras in your room will record what you do for 24 hours each day but not when you are in the bathroom or toilet. We can then compare the electrical activity in your brain with your actions during a seizure.
 
We may decrease or stop your epilepsy tablets. We may also keep you awake during the night. This will make it more likely that you will have a seizure which we can record.

This test is done by the Neurophysiology Department (EEG team), who will send you more details before the test.

Neuropsychological interview and assessments

The Neuropsychologist will interview you and someone who knows you well, such as a family member or close friend.

You will be asked questions and complete tests to look at your thinking abilities. The Neuropsychologist will assess your mental health such as any stress you have, depression, memory, and language functions.

These tests will help us to understand how your thinking abilities are affected by your epilepsy and if you might have problems with memory or language after surgery.

The results will also help the team to understand what support you might need before or after surgery.

The assessment usually takes between four to five hours to complete and is done over two to three appointments.

You will also be offered a follow up appointment with the Psychologist to discuss the test results and you may be offered further therapy to help you with any memory or mental health problems.

You will have further appointments with the psychologist after surgery (see later).

Functional MRI

Depending on the results of other tests, we may recommend that you have a brain scan called an fMRI (functional Magnetic Resonance Imaging). This is the same as an MRI scan, except that we will ask you to do simple tasks during the scan.

The scan takes 45 minutes to one hour to do and it shows us the activity of your brain whilst you are doing these tasks. This can show which areas of your brain you use when you think of words and when you move. The results help us to plan the details of your surgery.

If we think that you need an fMRI before surgery then members of the epilepsy surgery team including the Neuropsychologist will discuss the test in more detail with you.

The Wada Test

Depending on the results of other tests, we might also recommend that you have a Wada Test. The Wada test is used to look at Language and Memory in more detail.

It works by temporarily putting one half of the brain to sleep for about five to ten minutes using an anaesthetic drug whilst the Neuropsychologist gives you simple tasks to assess your speech, understanding and memory.

A medical doctor (Radiologist) gives you the anaesthetic drug and you also have an EEG during the test.

We test both halves of the brain separately and the test takes about 1 hour in total, but you will need to stay in hospital overnight after the test.

The test should not be painful but can feel odd. There are some small risks which the doctor will discuss with you before you agree to the test.

If we think that you need a Wada test before surgery then members of the epilepsy surgery team including the Neuropsychologist will discuss the test in more detail with you.

Positron Emission Tomography (PET)

We recommend that some people have PET scans before we can decide about surgery. PET scans can give us information about which parts of the brain might be involved in your seizures.

The PET scan involves an injection with radioactive dye, which can then be traced as it travels through the brain.

It helps us to see parts of the brain that might not be working as well as other areas, which can give us more information about where your seizures are coming from.

This dye gives off small amounts of radiation. You will be asked to lie down on a bed with a large circular scanner at one end.

The radiation given off by the dye is then used to form a picture of the activity in your brain. The scan can take up to an hour.

Stereo EEG (SEEG)

Stereo Electro-encephalography or SEEG is a specialised EEG (brainwave test) that is performed for some patients who are being considered for epilepsy surgery. This test involves placing thin wires called depth electrodes into the brain to record electrical activity during seizures. This helps to pinpoint where epileptic seizures start in the brain and will help the team looking after you to decide whether brain surgery is an option for treatment of your epilepsy. You would need to be admitted to hospital for at least 7 days for the assessment. If the team think that you need SEEG to help us decide on surgery options, then the neurologist and other members of the team will discuss this further with you.

Deciding if surgery is for you

Every fortnight we have an Epilepsy Surgery Team Meeting, for all the people who take part in your care. We will discuss your test results at this meeting. We then decide if we can recommend surgery to you.

If we decide that surgery is likely to help, then it is up to you whether you would like to have it. The Neurosurgeon, Neurologist, Epilepsy Specialist Nurse and Neuropsychologist will help you to decide if you would like to go ahead. They will discuss the risks and benefits of the surgery with you.

There are risks associated with epilepsy surgery. These include infection, bleeding, stroke, seizures, vision problems, pain, thinking problems (for example with memory or speech), mood problems and a small risk to life.

There is also the risk that the surgery will not make your seizures any better. There is a small risk that your seizures could be made worse.

We will not suggest that you can have surgery unless these risks are small in your case and do not outweigh the benefits.

If you decide not to have the surgery, then that is fine. You should discuss your choice fully with your Neurologist, Neurosurgeon and Neuropsychologist. They will make sure that you have all the right information.

They may also be able to answer any worries that you might have. There is always the possibility of revisiting surgery in the future if you decide that it is not the right time for you.

What happens before the surgery?

If you decide to have the surgery, you will need to come to hospital to meet the neurosurgeon to discuss the operation and its specific risks and benefits.

If you decide to go ahead with surgery then you will be sent an appointment for a ‘pre-operative assessment’. This is to check that you are well enough to have surgery.

This will usually involve an ECG (a test to assess the health of your heart), blood tests and a blood pressure check.

You will be admitted to hospital on the day of your surgery. You will not be able to eat or drink for about 6 hours before the operation.

You will still need to take your epilepsy medication as usual.

What does the surgery involve?

The Neurosurgeon will discuss the details of your surgery with you beforehand. There are three main types of epilepsy surgery which we do at Salford Royal Hospital.

Temporal Lobectomy and Amygdalo-hippocampectomy

If you have Temporal Lobe Epilepsy, then we remove a part of your brain called the temporal lobe and two specific structures called the hippocampus and amygdala. This is called a ‘Temporal Lobectomy with amygdalo-hippocampectomy’.

Hemispherotomy

Epilepsy can be caused by large amounts of damage to only one side of your brain. If this is the cause of your epilepsy then we can disconnect the damaged side of your brain from the normal side. This is called a ‘Hemispherotomy’.
 
This is usually done with people who also have a long history of weakness down one side of the body caused by the damage to the opposite side of the brain.

Lesionectomy

Epilepsy can be caused by an area of brain which is not normal, but which has clear borders, such as a ‘cavernoma’ or a tumour. In this case, we remove this area of brain. This called a ‘Lesionectomy’.

For all these operations, you will be put to sleep with a general anaesthetic. The surgeon will then remove a small area of your skull to get to your brain. Afterwards, the bone is replaced and fixed to the rest of your skull.

The surgery usually takes a few hours, and most people stay in hospital for at least five days following the operation.

Before surgery, your hair will need to be shaved around the area that is going to be operated on. The surgeon will explain where this will be done, however, the hair usually grows back as normal after surgery and over the first few months.

You will also have a scar from surgery. The surgeon will explain where the scar will be, but it is usual for the scar to be covered by your hair when it grows back (unless your hair is very short) and the scar is not normally obvious to others.

What happens after the surgery?

Recovery from surgery

Before your surgery, your neurologist and neurosurgeon will talk to you about what results you can expect from your surgery. In most cases, the surgery is a success and patients find that they have fewer seizures. Sometimes, the surgery does not make the seizures any better.

The longer after your surgery that you go without having a seizure, the more likely it is that you will not have any in the future. People usually stay on epilepsy tablets for at least 12 months after the surgery and some are advised to continue with treatment long term. After that, you may decide with the Neurologist to slowly reduce the dose.

It can take a few months, and for some people more than 12 months, to feel back to normal after brain surgery. The team will discuss with you how you might feel in the first few months after surgery.

It is common to feel very tired in the first few weeks. You will need plenty of rest and may need some help with your day-to- day activities at first.

As you recover from the surgery, you may notice problems with balance, memory, language and concentration. It is also quite common to feel more/less emotional than before your surgery in the first few months. Some patients also have mood swings or feel irritable.

Not everyone has these problems but for people who do, most of these symptoms should improve over the first 12 months.

Usually, memory and language improve to a similar level as it was before surgery. So, if you had memory problems before surgery then you are likely to have memory problems after surgery.
 
However, some people’s memory or language abilities are worse after surgery. This may be hard to cope with at first, but you should not find that it stops you from doing your daily activities in the long-term.

Support after surgery

You can get help from the Epilepsy Surgery Team.

If needed, you may be offered therapy such as medication, psychological therapy to help with changes in your mood or thinking abilities, physiotherapy to help with any physical weakness or occupational therapy to help with any practical activities that you find difficult.

Routine appointments

6-8 weeks after your surgery, you will have a check-up with the neurosurgeon. After this, you should be able to travel and exercise.

The Epilepsy Specialist Nurse will see or speak to you at regular intervals after surgery and is available to talk to you over the telephone if you have worries or questions about the surgery or your recovery.

You will receive regular appointments with your Neurologist after surgery.

You will be followed up by the Neuropsychologist, who will send you an appointment at 3 months, 6 months, 12 months, and 2 years after surgery.

Your thinking abilities including memory will be tested in detail 12 months after surgery so that we can compare the results to how you did before surgery.

Who should I contact for advice or support?

You can speak directly to your Neurologist, Neurosurgeon, Epilepsy Specialist Nurse or Neuropsychologist. We can complete the contact details at the start of this booklet at your appointments.

The Epilepsy Nurse Specialist is available to give you advice and support over the telephone.

You may wish to speak to others who have had surgery before making your decision. The Epilepsy Nurse Specialist can put you in touch with other people who have had epilepsy surgery in the past.

Contact details

For more information about our department please contact:

Epilepsy Nurse Team, Department of Neurology, 3rd Floor, Humphrey Booth Building, Salford Royal Hospital, Stott Lane, Salford, M6 8HD.

Tel: 0161 206 2951 or email epilepsynurseteam@nca.nhs.uk