Surgical treatment of epilepsy - Initial experience from a comprehensive epilepsy program in coastal South India

Abstract

Objectives: The objectives of this study were to share our initial experience with epilepsy surgery and provide an overview on the surgical treatments of epilepsies.

Materials and methods: This was a retrospective analysis of the demographics and clinical and investigative features of patients who underwent epilepsy surgery between January 2016 and August 2021. Postoperative seizure outcome was categorized according to modified Engel's classification, and the minimum period of follow-up was 1 year.

Results: The study group included 30 patients with an age ranging from 6 years to 45 years (mean: 22.28 years, median: 20 years) and a male: female ratio of 20:10. The epilepsy duration before surgery ranged from 3 years to 32 years (median: 7 years). Majority of our patients underwent resective surgeries (28/30 = 93.3%), and disconnection procedures were done in two patients. This included one functional hemispherotomy and one posterior quadrantic disconnection. Temporal lobe resective surgery was the most common procedure (16/30 = 53.3%), followed by eight frontal lobe and two parietal lobe surgeries. Among resective surgeries, majority were lesional surgeries and the pathologies included mesial temporal sclerosis (4), dysembryoplastic neuroepithelial tumor (8), ganglioglioma (6), cavernoma (4), focal cortical dysplasia (2), gliosis (1), and one case of hypothalamic hamartoma. Intraoperative electrocorticography was used in all cases for optimizing surgical resection/disconnection. Nearly two-thirds of our patients (66.6%) had an Engel's Class I outcome, five patients had Engel's Class II outcome, three patients had Class III outcome, and one patient did not have any worthwhile improvement. Temporal lobe surgery patients had a better seizure outcome compared to extratemporal surgeries (84% vs. 74%). Overall, complications were minimal and short lasting, and comprised meningitis in three patients (5.6%) and transient worsening of hemiparesis following hemispherotomy in two patients. There was no mortality or long-lasting major morbidity in our patients.

Conclusion: In carefully selected patients with drug-resistant epilepsy, surgery offers an excellent chance of becoming seizure-free with significant improvement in overall quality of life. Majority of the common epilepsy surgery procedures can be performed through a multidisciplinary approach even in centers with limited resources.

Keywords: Antiseizure medication; Drug-resistant epilepsy; Electrocorticography; Hemispherotomy; Surgery for epilepsy; Temporal lobectomy.

Figure 1:

Magnetic resonance imaging images of selected patients with surgically remediable epilepsy syndromes. (a) Right temporal mesial temporal sclerosis (Patient 8); (b) Right temporal gangliogliomas (Patient 14); (c) Right temporal uncal low-grade glioma (Patient 14); (d) Right temporal cavernoma (Patient 29); (e) Right temporal dysembryoplastic neuroepithelial tumor (Patient 20); (f) Rasmussen’s encephalitis (Patient 5).